Pancreatoduodenectomy in a patient with complete atherosclerotic occlusion of superior mesenteric artery: A case report

Introduction and importance: In elderly patients with atherosclerotic disease the occlusion of splanchnic arteries is a frequently observed variation, which doesn't normally affect patient's condition. There are sporadic reports on pancreatoduodenectomy in these cases. Case presentation: A 72-year-old female was admitted to our department with cancer of the ampulla of Vater. Preoperative CT-angiography revealed total atherosclerotic occlusion of the main trunk of the superior mesenteric artery (SMA). Collateral circulation was conducted through gastroduodenal and dorsal pancreatic artery. Pancreatoduodenectomy was performed with an intraoperative clamping test, which showed no signs of bowel ischemia. The patient was discharged on post-operative day 14 without any complications, and long-term followup revealed adjustment of collateral circulation through the inferior mesenteric artery and Riolan's arcade. Clinical discussion: Most cases of mesenteric artery stenosis occur in patients with underlying cardiac condition. As the occlusion develops chronically, it doesn't cause any symptoms due to collateral circulation, and no preoperative intervention is usually needed. However, there are rare cases reported in the literature, when preoperative endovascular stenting and SMA dilation were performed before pancreatoduodenectomy. In this report we decided to proceed with surgery upfront and perform an intraoperative clamping test. Conclusion: In this report we present a rare case of successful pancreatoduodenectomy in a patient with total atherosclerosis of the superior mesenteric artery. The intraoperative clamping test allowed us to assess both the sufficiency of collateral circulation and the feasibility of the surgery.