Hybrid hepatic artery debranching for pancreatic cancer with celiac axis occlusion

Pancreatic ductal adenocarcinoma (PDAC) is classified as resectable [resectable pancreatic cancer (RPC)], borderline resectable [borderline resectable pancreatic cancer (BRPC)], or locally advanced [locally advanced pancreatic cancer (LAPC)] according to the extent of arterial and venous involvement, most frequently affecting the celiac axis, hepatic artery, superior mesenteric artery (SMA), and porto-mesenteric venous axis (1,2). In BRPC and LAPC, vascular invasion often represents the primary barrier to achieving an R0 resection, with venous resection now widely regarded as a safe and feasible procedure in high-volume centers (3-5). In contrast, arterial resection, particularly involving the celiac axis or hepatic artery, remains technically demanding and carries a higher perioperative risk (6-8). It is generally reserved for carefully selected patients without disease progression following neoadjuvant therapy, in whom it may confer a survival advantage (5,9,10).

The development of advanced vascular techniques has broadened the therapeutic options for complex pancreatic cancer cases, enabling intraoperative or staged revascularization to be performed in conjunction with tumor resection. This is especially relevant in patients with chronic celiac axis occlusion, in whom restoration of hepatic arterial inflow, such as by an aorto-hepatic bypass, may be essential to facilitate curative-intent surgery.

To date, the application of endovascular interventions within pancreatic surgery remains scarcely reported. We describe a case of PDAC with chronic celiac axis occlusion managed by a hybrid aorto-hepatic bypass, emphasizing technical considerations, perioperative strategy, and the role of combined open and endovascular approaches in complex hepatopancreatobiliary oncology.

A 67-year-old male with a known history of chronic pancreatitis, arterial hypertension, and rheumatoid arthritis was referred to our unit for evaluation of a newly detected cystic-appearing peripancreatic lesion in the pancreatic head region. Cross-sectional imaging raised suspicion of PDAC with possible vascular involvement, but cytology from prior fine needle aspiration had been inconclusive. At the time of admission, there was no histologically confirmed malignancy. Given the indeterminate nature of the lesion and the clinical suspicion of PDAC, a robot-assisted laparoscopic exploration was scheduled to confirm the diagnosis and assess resectability. The external computed tomography (CT) scan showed no evidence of celiac trunk stenosis. The patient underwent standard preoperative preparation, including prophylactic antibiotics and thromboprophylaxis. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Robot-assisted laparoscopic exploration, conversion to open laparotomy, cholecystectomy

After induction of general anesthesia, the abdomen was insufflated via Veress needle and access was obtained through four 8 mm robotic trocars and one 12-mm assistant port. Initial laparoscopy revealed no evidence of peritoneal carcinomatosis or liver metastases. Upon entering the lesser sac through the gastrocolic ligament, extensive peripancreatic collaterals were noted over the pancreatic head. The portal vein could be partially visualized, but the anatomy of the hepatic artery could not be safely delineated due to distortion by the mass and surrounding collaterals. Doppler assessment indicated diminished pulsatility in the hepatic artery.

Given the unclear arterial anatomy and the evidence of focal pancreatitis following fine needle aspiration (FNA) and the risk of compromising hepatic arterial inflow, the procedure was converted to an open upper midline laparotomy. Multiple biopsies were taken from the omentum minus, cyst wall, pancreatic margins, and celiac region for intraoperative frozen section analysis. They were all negative for malignancy. An antegrade cholecystectomy was performed for further exposure and specimen acquisition. The abdomen was irrigated, a single Easy-Flow drain was placed in the hepatoduodenal ligament, and the patient was transferred intubated to the intensive care unit for postoperative monitoring. Definitive histological analysis following surgery confirmed the diagnosis of PDAC.

Diagnostic transfemoral angiography

Given the intraoperative finding of reduced hepatic arterial pulsatility, a diagnostic and potential therapeutic angiogram was performed via the left brachial artery under local anesthesia to assess for celiac axis stenosis. Angiography demonstrated complete occlusion of the celiac trunk with robust collateral filling of the hepatic artery from the SMA via the pancreaticoduodenal arcade. No suitable stump or short-segment stenosis amenable to percutaneous recanalization could be identified, consistent with a chronic process with fibrotic occlusion. No intervention was performed at this time (Figure 1—angiography showing celiac axis occlusion and collateral pathways from SMA).

Figure 1 Diagnostic transfemoral angiography demonstrating complete celiac trunk occlusion with well-developed collateral. (A) Angiography of the superior mesenteric artery; (B) aortography. Arrow: filling of the hepatic artery via the pancreaticoduodenal arcade from the superior mesenteric artery.

Relaparotomy, aorto-hepatic debranching, intraoperative angioplasty and stenting

Given the patient’s stable condition and need to secure hepatic inflow before pancreatic resection, an aorto-hepatic bypass was planned. After re-entering the abdomen through the midline incision and performing a complete Cattell-Braasch maneuver, the infrarenal aorta was dissected free. A reversed segment of left great saphenous vein was harvested. Following systemic heparinization an end-to-side anastomosis was constructed between the vein graft and the infrarenal aorta using 5-0 Prolene. The graft was routed posterior to the pancreas to reach the gastroduodenal artery (GDA), where an end-to-end anastomosis was fashioned with 7-0 Prolene (Figure 2—aorto-GDA bypass).

Figure 2 Intraoperative view of the aorto-gastroduodenal artery bypass using a reversed left great saphenous vein graft.

Initial intraoperative flow measurements revealed poor hepatic inflow (<50 mL/min). Intraoperative angiography via right common femoral artery puncture showed a high-grade stenosis at the GDA stump. This was treated with implantation of a 5 mm × 22 mm covered stent (Bentley), achieving an immediate improvement in graft flow to 250 mL/min (Figure 3A—intraoperative angiography pre-stenting, Figure 3B—post-stenting result). The bypass and stent were left patent with palpable hepatic pulsation. The abdomen was irrigated, a drain was placed retroduodenally, and the patient was returned to intensive care for close hemodynamic and laboratory monitoring.

Figure 3 Intraoperative angiography before and after covered stent placement at the gastroduodenal artery stump demonstrating resolution of high-grade stenosis and restoration of hepatic arterial perfusion. (A) Intraoperative angiography before stent placement, revealing high-grade stenosis at the gastroduodenal artery stump following bypass construction. Arrow: high-grade stenosis. (B) Intraoperative angiography after placement of a 5 mm × 22 mm covered stent (Bentley), showing restored flow with improved opacification of the hepatic arterial tree.

Total duodenopancreatectomy

With hepatic inflow secured, the patient proceeded to resection. Due to pancreatitis and the risk of a pancreatic fistula potentially causing erosion of the bypass, a total duodenopancreatectomy was performed. Reconstruction was achieved via end-to-side hepaticojejunostomy, side-to-side gastrojejunostomy, and side-to-side jejunojejunostomy. The aorto-hepatic graft demonstrated excellent pulsatility throughout the procedure. Frozen section analysis confirmed no evidence of distant spread. The postoperative course was notable for an uneventful recovery from the pancreatic resection perspective.

Postoperative course

Postoperative CT angiography (Figure 4A—coronal reconstruction, Figure 4B—axial view) confirmed patency of both the aorto-hepatic bypass and the covered stent, with uniform enhancement of the hepatic arterial tree. No early graft thrombosis or anastomotic complication was observed. The patient developed a localized hematoma at the saphenous vein harvest site, which was drained and managed with local wound care. He also required initiation of insulin therapy for new-onset pancreoprivic diabetes mellitus.

Figure 4 Postoperative CT angiography confirming patency of the aorto-hepatic bypass with intact proximal and distal anastomoses and no evidence of stent thrombosis or anastomotic complication. (A) Postoperative CT angiography confirming patency of the aorto-hepatic bypass and proximal anastomosis. Arrow: proximal anastomosis. (B) Postoperative CT angiography showing unobstructed distal anastomosis and intact stent without evidence of thrombosis or anastomotic complication. Arrow: distal anastomosis. CT, computed tomography.

Histology revealed a moderately differentiated ductal adenocarcinoma (G2), pT2 pN1 (1/39), with R0 resection margins. Multidisciplinary tumor board recommended adjuvant mFOLFIRINOX [modified folinic acid (leucovorin), fluorouracil, irinotecan, and oxaliplatin] chemotherapy. The patient was discharged after a 23-day hospital stay, in good general condition, with lifelong aspirin 100 mg daily and instructions for regular imaging surveillance of the bypass graft and stent.

Discussion

Arterial involvement in PDAC remains one of the most challenging scenarios in pancreatic surgery. While venous resection is now well established and considered safe in high-volume centers (3-6), arterial resection, especially involving the celiac axis or hepatic artery, carries significantly higher perioperative morbidity and mortality (6-9). In carefully selected patients, however, it may confer a survival benefit, particularly when performed after disease stability or regression on neoadjuvant therapy (5,9-11).

The patient’s carbohydrate antigen 19-9 (CA19-9) level was within the normal range (17.3 U/mL), which supported the initial assessment of a resectable disease. Because the tumor showed no radiologic evidence of arterial involvement, neoadjuvant chemotherapy was not administered; the need for a bypass arose solely from pre-existing celiac trunk occlusion rather than tumor infiltration. During surgery, an aorta-GDA bypass was selected based on intraoperative judgment and suitable anatomical exposure, with no strong advantage expected from an aorta-proper hepatic artery (PHA) alternative. When postoperative stenosis occurred, endovascular stenting was chosen as the least invasive and technically straightforward option. Should the stent fail, a definitive surgical bypass to the hepatic artery would be the next step. Overall, with complete resection and the addition of adjuvant chemotherapy, the patient’s long-term prognosis is considered favorable.

Our patient presented with suspected PDAC in the pancreatic head in the context of chronic celiac axis occlusion. Chronic occlusion of the celiac trunk is rare in PDAC patients but poses unique technical challenges, as hepatic arterial inflow is entirely dependent on retrograde flow from the SMA via the pancreaticoduodenal arcade. In the setting of pancreatic head resection, this collateral pathway is disrupted, risking acute hepatic ischemia unless arterial reconstruction is performed.

Historically, this situation has been addressed through open surgical bypasses, most commonly an aorto-hepatic or aorto-GDA bypass using autologous conduit (7,8,10). However, graft kinking, poor inflow, or anastomotic stenosis may compromise the bypass. In our case, intraoperative flow measurement revealed inadequate hepatic inflow despite anatomically correct graft placement. The immediate integration of intraoperative angiography allowed rapid diagnosis of a high-grade stenosis at the GDA stump, which was effectively treated with covered stent placement. This hybrid approach, combining open bypass with endovascular optimization, resulted in a marked increase in graft flow (from <50 to 250 mL/min) and ensured reliable hepatic inflow prior to pancreatic resection.

The literature on hybrid revascularization in pancreatic surgery is limited, with most reports focusing on either open arterial reconstruction (12) or endovascular preconditioning procedures, such as celiac stenting or embolization of collateral pathways to stimulate collateral hypertrophy. To our knowledge, intraoperative stenting of a newly constructed bypass to optimize flow before proceeding to PDAC resection is rarely reported. This case demonstrates the feasibility and safety of combining both modalities in a single operative setting.

Key technical considerations include meticulous preoperative vascular imaging to delineate occlusion length and collateral pathways, the choice of autologous conduit to accommodate long bypass length and minimize infection risk, and readiness to perform endovascular adjuncts intraoperatively if flow remains suboptimal. In our patient, the use of the great saphenous vein provided an adequate diameter and length, while intraoperative angiography offered real-time feedback for targeted endovascular intervention.

Postoperatively, early graft patency was confirmed by CT angiography, and the patient experienced no ischemic or anastomotic complications. Lifelong antiplatelet therapy and structured vascular imaging follow-up are essential to detect late graft or stent complications, which remain a concern in long-term survivors.

From an oncological perspective, achieving an R0 resection in a patient with pT2 pN1 PDAC and chronic vascular occlusion required a staged approach involving hepatopancreatobiliary surgeons with proficiency in vascular and endovascular surgery. This setting not only allowed safe resection but also preserved hepatic perfusion, enabling timely initiation of adjuvant chemotherapy, critical for optimizing long-term outcomes in PDAC (1,2).

In conclusion, this case highlights the role of hybrid open-endovascular techniques in complex PDAC surgery with chronic celiac axis occlusion. In selected patients, these strategies can expand resectability criteria, prevent catastrophic hepatic ischemia, and facilitate oncologically complete resections. Future studies should evaluate the durability of such reconstructions and their impact on long-term survival in comparison with standard open bypass techniques.

Conclusions

Hybrid surgical-endovascular strategies can provide a safe and effective solution for securing hepatic arterial inflow in pancreatic cancer patients with chronic celiac axis occlusion. This case demonstrates the successful use of an aorto-GDA bypass with intraoperative stent placement, enabling curative-intent total duodenopancreatectomy and R0 resection. Endovascular expertise among pancreatic surgeons is rare but may become crucial in minimally invasive and robotic surgery for borderline resectable and locally advanced PDAC.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-714/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-714/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

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