JUSTIFICATION FOR VISCERAL ANGIOGRAPHY PRIOR TO PANCREATICODUODENECTOMY

The hepatic arterial anatomy is aberrant in almost 50 per cent of all individuals. The most common anomalies include the right hepatic arter y arising from the superior mesenteric artery (25%) and the left hepat ic artery arising from the left gastric artery (25%). Anomalies of the common hepatic artery, usually a branch of the celiac artery, are rar e. A replaced common hepatic artery originating from the superior mese nteric artery occurs in 2.5% of the entire population. Injury to hepat ic blood supply is more common in the presence of aberrant arterial an atomy. Knowledge of aberrant arterial anatomy in patients about to und ergo pancreaticoduodenectomy can lead to measures to preserve the vess els, and avoid fatal hepatic injury. We present a patient with a repla ced common hepatic artery originating from the superior mesenteric art ery successfully treated with a standard pancreaticoduodenectomy for p ancreatic adenocarcinoma. The anomalous vessel was identified on visce ral angiography, performed as part of the initial preoperative evaluat ion. At the time of laparotomy, the artery followed a course atypical for replaced hepatic arteries, lying medial to the common bile duct, a nd closely mimicking the gastroduodenal artery that would normally be divided during a Whipple procedure. This case emphasizes the importanc e of preoperative visceral angiography and the margin of safety it can provide when that knowledge is used in the operative strategy. Viscer al angiography should be considered routine before pancreaticoduodenec tomy, particularly in surgical residency training programs.