Severe Abdominal Aortic Calcification in Pancreaticoduodenectomy: A Vascular Frailty Marker for Selecting Total Pancreatectomy?

Postoperative pancreatic fistula remains one of the most consequential complications after pancreaticoduodenectomy, particularly when it triggers post-pancreatectomy haemorrhage, sepsis, reoperation and failure to rescue. Current fistula risk models mainly capture local pancreatic factors, but they incompletely reflect systemic vascular frailty and the patient's capacity to tolerate major complications. Abdominal aortic calcification is frequently visible on routine preoperative computed tomography and may provide an opportunistic marker of systemic atherosclerosis, impaired microvascular reserve, sarcopenia, frailty and reduced physiological resilience. Emerging evidence suggests that severe abdominal aortic calcification, particularly when quantified by CT-based scores or volumetric methods, is associated with clinically relevant postoperative pancreatic fistula, major complications and poorer outcomes after pancreatic surgery. In parallel, contemporary data suggest that planned total pancreatectomy, although metabolically demanding, may be feasible in selected high-risk patients when supported by modern diabetes care, pancreatic enzyme replacement and structured follow-up. This narrative review examines whether severe abdominal aortic calcification should be integrated into risk stratification before pancreaticoduodenectomy and whether, in carefully selected patients with very high fistula risk and limited rescue capacity, it may contribute to the discussion between pancreatic reconstruction and planned total pancreatectomy.