Pancreatic Cancer with Concomitant Median Arcuate Ligament Syndrome Requiring Arterial Reconstruction During Pancreaticoduodenectomy: A Case Report.

INTRODUCTION:Pancreatoduodenectomy (PD) for pancreatic head malignancies can be complicated by coexisting vascular anomalies. Median arcuate ligament syndrome (MALS), occurring in 2.1%-7.6% of PD cases, causes celiac artery (CA) stenosis and poses a significant risk of ischemic complications. While division of the median arcuate ligament (MAL) may restore blood flow in some cases, arterial reconstruction is occasionally necessary. We report a challenging case of pancreatic head adenocarcinoma with MALS requiring emergent intraoperative arterial reconstruction. CASE PRESENTATION:A 69-year-old man presented with a 31-mm pancreatic head tumor in contact with the superior mesenteric artery (SMA) and complete CA occlusion due to MALS. Preoperative imaging revealed well-developed collateral circulation via the dorsal pancreatic artery (DPA). After 6 cycles of neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel, the tumor decreased to 18 mm. Anticipating the potential need for arterial reconstruction during PD, preoperative simulations were conducted with the vascular surgery team. Intraoperatively, MAL division was performed, and a gastroduodenal artery (GDA) clamp test confirmed adequate hepatic arterial flow via the DPA. However, hepatic arterial flow ceased during subsequent surgical manipulation, requiring emergent arterial reconstruction. Initial middle colic artery-GDA anastomosis was complicated by repeated thrombosis; definitive reconstruction using a lesser saphenous vein graft successfully restored hepatic arterial flow. Pathological examination revealed a complete pathological response. The patient was discharged on POD day 18 without major complications and remains recurrence-free at 22 months. CONCLUSIONS:This case demonstrates that in PD for patients with concomitant MALS, collateral circulation may be disrupted by intraoperative manipulation, potentially necessitating emergent arterial reconstruction. Therefore, meticulous preoperative imaging evaluation, vigilant intraoperative monitoring of hepatic arterial flow, and thorough preparation for vascular reconstruction are essential for the safe management of these complex cases.