Sequential Flow-Based Assessment of a Suspected Inferior Pancreaticoduodenal Artery-Derived Pathway Entering the Right Hepatic Artery during Pancreaticoduodenectomy: A Case Report.

INTRODUCTION: During pancreaticoduodenectomy (PD), hepatic arterial ischemia is usually considered in patients with celiac artery stenosis or occlusion, in whom the gastroduodenal artery (GDA)-based pancreaticoduodenal arcade may serve as a critical collateral pathway. However, a similar but atypical pitfall may exist when the GDA and anterior superior pancreaticoduodenal artery (ASPDA) are absent: a prominent inferior pancreaticoduodenal artery (IPDA)-derived pathway may raise concern regarding hepatic inflow despite the anatomical presence of the common hepatic artery (CHA).

CASE PRESENTATION: A 75-year-old man with distal bile duct cancer underwent preoperative evaluation for PD. Contrast-enhanced CT showed an anatomically identifiable CHA measuring 3.4 mm, whereas the GDA and ASPDA were absent. A markedly developed IPDA-derived arterial pathway coursed cranially from the superior mesenteric artery and appeared to enter the main trunk of the right hepatic artery (RHA) within the hepatoduodenal ligament, raising concern that its division might affect hepatic arterial inflow. Balloon occlusion was performed immediately proximal to the point where the pathway appeared to enter the RHA. During occlusion, aortography showed opacification of the CHA and RHA through the CHA without visually apparent delay. Intraoperatively, temporary clamping with indocyanine green fluorescence imaging showed visually uniform liver surface fluorescence without a subjective right-left difference in fluorescence onset. The pathway was divided, and PD was completed without median arcuate ligament release or arterial reconstruction. Postoperative contrast-enhanced CT on POD 6 confirmed preserved hepatic arterial opacification without ischemic changes.

CONCLUSIONS: An anatomically identifiable CHA does not necessarily guarantee secure hepatic arterial inflow during PD. When the GDA and ASPDA are absent and an IPDA-derived pathway is markedly developed, functional assessment should be considered before irreversible arterial division.