Celiac Artery Stenosis: An Underappreciated and Unpleasant Surprise in Patients Undergoing Pancreaticoduodenectomy

Because of the prevalence of CAS, the pancreatic surgeon needs to maintain a high index of suspicion whenever the preoperative imaging shows extensive pancreatic arterial collateralization, or when intraoperative findings show extensive pancreaticoduodenal collateral vessels, an enlarged GDA, or other unusual arterial anatomy. Because PD disrupts or resects these collateral pathways, potentially providing the only arterial supply to the celiac artery distribution, the ability to revascularize a branch of the celiac artery or to maintain certain collateral supply must be readily available in the operative armamentarium. The type of revascularization depends on the cause of CAS-either celiac decompression for external compression or vascular bypass/celiac branch reimplantation for ostial stenosis. Preoperative diagnosis offers the potential for preoperative revascularization through minimally invasive endovascular techniques. Although the need for aggressive revascularization is rare, when needed, it is imperative, and the surgeon needs to be prepared.