Retrograde open celiac stenting for ischemic hepatitis after pancreaticoduodenectomy

A 74-year-old man with pancreatic cancer had undergone pancreaticoduodenectomy and subsequently developed ischemic hepatitis secondary to high-grade celiac artery stenosis. Celiac antegrade stenting via brachial artery access was unsuccessful, and open antegrade bypass would have required takedown of the pancreatic and/or biliary anastomoses for adequate exposure. Retrograde open celiac stenting was, therefore, successfully performed via the gastroduodenal artery stump. His ischemic hepatitis resolved, and he was ultimately discharged with dual antiplatelet therapy. Computed tomography angiography at 6 months demonstrated a widely patent celiac stent. Retrograde open celiac stenting via the gastroduodenal artery stump is an alternative to open bypass for celiac revascularization not amenable to percutaneous antegrade stenting in patients who have undergone pancreaticoduodenectomy.

confirmed these findings. His antiplatelet regimen was deescalated to aspirin monotherapy, and he resumed adjuvant chemotherapy. The patient remained without evidence of recurrent cancer at 6 months after his curative intent surgery.

DISCUSSION
Mesenteric atherosclerotic disease is increasingly common in an aging population. Intestinal perfusion is dependent on rich collateral networks between the mesenteric vessels. The incidence of celiac artery stenosis ranges from 10% to 25%. 1 The predominant collateral between the celiac artery and SMA is the pancreaticoduodenal arcade, which will be interrupted by ligation of the GDA during pancreaticoduodenectomy. Thus, patients undergoing pancreaticoduodenectomy in the setting of celiac disease will be prone to postoperative liver failure or biliary stricture formation. 1 In a retrospective, single-institution review, ischemic hepatitis occurred in 5 of 545 patients (0.9%) who had undergone pancreaticoduodenectomy. In addition, 5% of this cohort had had hemodynamically significant visceral stenoses based on selective visceral angiography that had been stented preoperatively (n ¼ 3), bypassed intraoperatively (n ¼ 1), or treated by median arcuate ligament division (n ¼ 23). 2 Revascularization of high-grade celiac stenoses should be performed before pancreaticoduodenectomy whenever possible to mitigate later ischemic complications.
Historically, open bypass was the preferred method for mesenteric revascularization. However, contemporary trends have favored an endovascular first approach, ranging from percutaneous stenting to retrograde open mesenteric stenting (ROMS). During the past 15 years, the popularity of hybrid stenting for SMA revascularization in the presence of acute and chronic mesenteric ischemia has increased. [3][4][5][6][7][8][9][10] In patients with acute mesenteric ischemia, an initial laparotomy will frequently be performed to assess intestinal viability. ROMS offsets the risk of supraceliac aortic exposure and graft infection associated with bypass. A number of institutional studies have reported excellent technical success and short-and mid-term outcomes for ROMS. 4,7,9,10  Because the SMA will be preferentially revascularized to treat acute and chronic mesenteric ischemia, a paucity of data is available describing the ROMS technique for celiac artery revascularization. Rego et al 11 described an elderly man with concomitant SMA occlusion and high-grade celiac stenosis who had undergone oncologic resection of a distal gastric cancer and had developed septic shock due to anastomotic dehiscence with subsequent open repair. In this low-flow state, acute mesenteric ischemia and ischemic hepatitis ensued, requiring repeat laparotomy, total abdominal colectomy, small bowel resection, and splenectomy. Retrograde open celiac artery stenting via the splenic artery stump restored hepatic arterial perfusion without additional morbidity. Their case was the first to extrapolate from the extensive experience in the literature on ROMS for SMA revascularization to celiac artery recanalization.
Celiac artery revascularization unamenable to percutaneous stenting is a unique clinical scenario in patients after pancreaticoduodenectomy. Supraceliac aorta to hepatic artery antegrade bypass is a well-described technique 12 ; however, the pancreaticojejunostomy and hepaticojejunostomy anastomoses will limit the exposure for bypass. Likewise, the potential exists, albeit low, for the risk of graft infection similar to that with renohepatic bypass. Retrograde celiac artery stenting (ROCS) provides an alternative method for celiac artery revascularization. The GDA stump will be ligated as part of the pancreaticoduodenectomy and provides a viable option for sheath placement while minimizing the risks of accessrelated complications to the common hepatic artery. In addition to intraluminal recanalization, a technical challenge to this approach is a celiac trunk with enough length to accommodate a balloon-expandable stent graft without sacrificing the visceral branches such as the left gastric artery, which is important for gastric  perfusion after pancreaticoduodenectomy. If these obstacles can be overcome, ROCS via the GDA stump can provide an elegant solution for celiac artery revascularization. This technique is most widely applicable using a mobile C-arm at the time of pancreaticoduodenectomy when dampening or loss of the hepatic artery pulse occurs during GDA test clamping as a prophylactic intervention.

CONCLUSIONS
Similar to ROMS for SMA revascularization, ROCS is a viable alternative to percutaneous stenting and bypass for celiac artery lesions. For patients who have undergone pancreaticoduodenectomy, the GDA stump provides a safe retrograde access point to the celiac artery for hybrid stenting.