Laparoscopic distal pancreatectomy in a patient with aberrant splenic artery originating from the superior mesenteric artery: A case report.

RATIONALE: Splenic artery originating from the superior mesenteric artery is extremely rare. Because of this, its significance in laparoscopic distal pancreatectomy has never been reported. Here, we present the first case of laparoscopic distal pancreatectomy in a patient with a splenic artery arising from the superior mesenteric artery. PATIENT CONCERNS: A 46-year-old Japanese woman with type 2 diabetes mellitus presented with worsening glycemic control. Abdominal ultrasonography revealed a pancreatic tail mass. DIAGNOSES: The patient was diagnosed with pancreatic neuroendocrine tumor by endoscopic ultrasound-guided fine needle aspiration. Preoperative computed tomography showed that the splenic artery with branches of dorsal pancreatic artery originated from the superior mesenteric artery. INTERVENTIONS: The patient underwent laparoscopic distal pancreatectomy. Prior to pancreatectomy, the splenic artery and its dorsal pancreatic branches were clamped using the superior and inferior approaches, respectively, to avoid bleeding and congestion. OUTCOMES: The postoperative course was uneventful. LESSONS: Preoperative evaluation of anatomical variants and development of strategies are important to avoid intraoperative complications in pancreatic surgery. Our results revealed that laparoscopic distal pancreatectomy can be performed safely by strategic approach even in a patient with a rare aberrant splenic artery.

Endovascular Treatment of Aberrant Splenic Artery Aneurysm Presenting With Painless Progressive Jaundice: A Case Report and Literature Review.

Splenic artery (SA) originating from the superior mesenteric artery is a rare condition, and aneurysms in relation to this aberrant SA are even rarer. We reported the case of a 67-year-old female who presented with painless progressive jaundice for 2 months accompanied by thrombocytopenia and liver dysfunction. The computed tomographic angiography (CTA) showed an aberrant SAA located behind the pancreatic head along with the dilation of common bile duct. Stent-graft deployment in SMA and coil embolization of the aneurysm were performed. Her liver dysfunction and thrombocytopenia improved postoperatively. CTA at 2-year follow-up showed patency of stent-graft and SMA and the shrinkage of the excluded aneurysm sac. Considering the particular location of the aneurysm, painless progressive jaundice can be the initial symptom for the aberrant SAAs. This combined endovascular technique completely excluded the aneurysm and was beneficial for treating secondary liver dysfunction and thrombocytopenia.

A systematic review of splenic artery variants based on cadaveric studies.

PURPOSE: The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches. METHODS: The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns. RESULTS: Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%. CONCLUSION: Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.

Quadrifurcation Variants of the Celiac Trunk.

BACKGROUND: The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate. METHODS: The CT quadrifurcations were documented on 112 computed tomography angiograms. RESULTS: Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P = 0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA + right hepatic artery+GDA pattern, type 2 had an HGT + right inferior phrenic artery + CHA + SA pattern, type 3 had a gastrophrenic trunk + left inferior phrenic artery+CHA + SA pattern, type 4 showed an left gastric artery + CHA + SA + left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one. CONCLUSIONS: Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Unusual development of the celiac trunk and its clinical significance / Desenvolvimento incomum do tronco celíaco e sua importância clínica

Abstract We describe a case of unusual development of the celiac trunk observed in the cadaver of 1-year old male child. The celiac trunk branched into five vessels: the splenic, common hepatic and left gastric arteries, the left inferior diaphragmatic artery, and a short trunk that branched into the right inferior diaphragmatic artery and right accessory hepatic artery. Additionally, the manner of branching of the vessel was unusual: it was possible to distinguish two branching points that corresponded to its s-shaped trajectory. There were also other variations of vascular supply, such as the presence of a left accessory hepatic artery, an additional superior pancreatoduodenal artery, and others. It should be noted that multiple developmental variations can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.

Resumo Apresentamos um relato de caso de desenvolvimento incomum do tronco celíaco em um cadáver do sexo masculino de 1 ano de idade. O tronco celíaco ramificou-se para cinco vasos: as artérias esplênica, hepática comum e gástrica esquerda, a artéria diafragmática inferior esquerda e um tronco pequeno que se ramificou para a artéria diafragmática inferior direita e para a artéria hepática direita acessória. Além disso, a forma como o vaso se ramificou foi incomum: é possível distinguir dois pontos de ramificação que correspondem à trajetória em formato de S. Também houve outras variações do suprimento vascular, como a presença da artéria hepática esquerda acessória, da artéria pancreaticoduodenal superior acessória e outras. Cabe observar que a variação de desenvolvimento múltipla pode ser comum na prática clínica, e os médicos devem estar cientes dela durante os procedimentos de diagnóstico e intervenção.

Anomalous Course of Accessory Splenic Arteries in Gastrosplenic Ligament: Case Report and Clinico-Embryological Basis.

Accessory splenic arteries in the gastrosplenic ligament constitute one of the extremely sub-component of abdominal vasculature variations and it is imperative to recognize this anomaly while planning for complex surgeries in the supra-colic compartment. We report the case of accessory splenic arteries in an approximately 50-year-old male cadaver encountered during routine educational dissection. One of them arising from left gastroepiploic artery supplies the spleen in addition to splenic artery. Another variant vessel bifurcated to enter greater omentum and anterior pole of spleen, as discrete branches. The anatomical vascular variation, if recognized during the imaging work-ups for elective surgical procedures could avoid potential iatrogenic blood loss.

Splenic artery tortuosity index on abdominal CT Scan: correlation with age, sex, BMI and abdominal cavity diameters / Índice de tortuosidad de la arteria esplénica en TC abdominal: correlación con la edad, el sexo, el IMC y los diámetros de la cavidad abdominal

Thorough knowledge of splenic artery course and morphology may help clinician to provide better practice. This Study aims at finding out if there was a relationship between splenic artery tortuosity index and age, sex, Body Mass Index (BMI) and abdominal cavity diameters. Routine abdominal Computerized Tomography (CT) scan images were retrospectively analyzed for 219 patients. Splenic artery tortuosity index was calculated. Abdominal cavity diameters were measured. Age, sex, and BMI were recorded. Splenic artery straight length (x) mean was 9.41 cm (SD 1.33). Splenic artery tortuous length mean was 15.15 cm (SD 3.31). Splenic artery tortuosity index mean was 1.63 (SD 0.36). Pearson correlation coefficient for Splenic artery tortuosity index vs. age was: 0.02 (P value 0.80). Splenic artery tortuosity index for females vs. males were 1.70 vs. 1.57 (P value 0.01). Pearson correlation coefficient for Splenic artery tortuosity index vs. BMI was 0.02 (P value 0.75). Pearson correlation coefficient for Splenic artery tortuosity index vs. abdominal cavity diameters were: Anterior-Posterior (AP) diameter -0.01 (P value 0.88) and transverse diameter 0.00 (P value 0.98). There may be a relationship between splenic artery tortuosity and female sex, but not with age, BMI and abdominal cavity diameters (AP and Transverse).

El conocimiento del curso y la morfología de la arteria esplénica puede ayudar al médico a proporcionar un diagnóstico y tratamiento oportuno al paciente. Este estudio tuvo como objetivo determinar si existe una relación entre el índice de tortuosidad de la arteria esplénica y la edad, el sexo, el índice de masa corporal (IMC) y los diámetros de la cavidad abdominal. Se tomaron imágenes retrospectivas, de rutina, de 219 pacientes de tomografía computarizada (TC) abdominal. Se calculó el índice de tortuosidad de la arteria esplénica. Se midieron los diámetros de la cavidad abdominal y se registró la edad, sexo y el IMC. La media de la longitud recta de la arteria esplénica (x) fue de 9,41 cm (DE 1,33). La longitud tortuosa de la arteria esplénica fue de 15,15 cm (DE 3,31). La media del índice de tortuosidad de la arteria esplénica fue de 1,63 (DE 0,36). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica vs. edad fue: 0,02 (valor de P 0,80). El índice de tortuosidad de la arteria esplénica para las mujeres frente a los hombres fue de 1,70 frente a 1,57 (valor de P 0,01). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica versus el IMC fue de 0,02 (valor de P 0,75). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica frente a los diámetros de la cavidad abdominal fue: diámetro anterior-posterior (AP) -0,01 (valor P 0,88) y diámetro transversal 0,00 (valor P 0,98). Puede existir una relación entre la tortuosidad de la arteria esplénica y el sexo femenino, sin embargo no se encontró relación con la edad, el IMC y los diámetros de la cavidad abdominal (AP y transversal).

Endovascular Repair Using a 7-Branch Stent-Graft for a Thoracoabdominal Aortic Aneurysm With Variant Renovisceral Artery Anatomy.

Purpose: To present a case of endovascular repair using a custom-made 7-branch stent-graft for a thoracoabdominal aortic aneurysm (TAAA) in a patient with variations in the renovisceral artery anatomy. Case Report: A 70-year-old asymptomatic man presented with a 60-mm-diameter type IV TAAA. Due to severe coronary artery disease, an endovascular approach was elected. In the preoperative computed tomography angiography (CTA) scans, variations in the renovisceral artery anatomy included the common hepatic and splenic arteries deriving separately from the aorta and bilateral double renal arteries (RAs). A custom-made 7-branch stent-graft was manufactured to preserve all renovisceral arteries. The 7 branches were catheterized and connected with a steerable sheath from a femoral access. All branches were bridged to the target vessel (TV) with a self-expanding covered stent; 4 TVs also had balloon-expandable covered stents implanted. Final angiography and predischarge CTA showed patency of all 7 target vessels and corresponding visceral organs, with no endoleak. The patient was discharged on postoperative day 8 without complications. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 7 target vessels. Conclusion: Successful treatment of a TAAA in a patient with multiple variant renovisceral arteries was feasible with a custom-made 7-branch stent-graft, achieving a good early outcome.

Unusual anatomical variation: tetrafurcation of the celiac trunk.

The celiac trunk is one of the main sources of vascularization of the supracolic abdominal compartment. It arises from the abdominal aorta, at the level of T12-L1 vertebrae and classically branches into the splenic artery, common hepatic artery, and left gastric artery. We report here an atypical branching pattern of the celiac trunk, found during the dissection of a 60-year-old female's formalin-fixed cadaver. The atypically celiac trunk gave rise to four branches: a common trunk for left and right inferior phrenic arteries, an accessory left gastric artery, the common hepatic artery, and a splenogastric trunk. Knowledge in detail about normal anatomy and variation in the branching pattern of the celiac trunk is important in surgical, oncological, and radiological interventional procedures and must be taken into account to avoid possible complications.

Endovascular Repair of Anomalous Splenic Artery Aneurysm with Systemic Lupus Erythematosus.

Splenic artery aneurysm with systemic lupus erythematosus is rare but serious. We report a case of a 45-year-old female with systemic lupus erythematosus who presented with a splenic artery aneurysm of anomalous origin from the superior mesenteric artery. This is the first time to report about using an endovascular approach to treat splenic artery aneurysm combined with systemic lupus erythematosus. Endovascular repair of the aneurysm was conducted using a covered stent and multiple coils to exclude both the aneurysm and total splenic artery embolization for treating thrombocytopenia, and this approach was determined to be safe and effective for yielding short-term results.

Tronco hepato-espleno-mesentérico: descripción de una disposición anómala del tronco celíaco / Hepato-splenic-mesenteric trunk: description of an abnormal disposition of the celiac trunk

El estudio de los patrones arteriales de distribución vascular requiere un conocimiento preciso de las variaciones anatómicas, tanto de origen y distribución de las arterias, como de sus correspondientes ramas arteriales. En este trabajo se describe la presencia de un tronco hepato-espleno-mesentérico, disposición arterial altamente infrecuente. El conocimiento de las distintas posibilidades de disposición de las arterias correspondientes al tronco celíaco y sus ramas será de importancia para la interpretación adecuada de estudios imagenológicos, como así también para la planificación precisa de actos quirúrgicos e intervencionistas en la región abdominal.

The study of arterial patterns of vascular distribution requires a precise knowledge of the anatomical variations of both origin and distribution of the corresponding arteries and arterial branches. In this work, the presence of a hepatosplenic-mesenteric trunk is described, a highly infrequent arterial disposition. The knowledge of the different possibilities of disposition of the arteries corresponding to the celiac trunk and its branches will be of importance for the adequate interpretation of imaging studies, as well as for the precise planning of surgical and interventional acts in the abdominal region.

Aberrant gastroduodenal artery with splenic origin.

PURPOSE: Knowledge of the wide variability in celiac trunk branches is of paramount importance when planning an abdominal surgery. METHODS: We, hereby, report a previously undescribed origin of the gastroduodenal artery discovered on an abdominal angio-CT. RESULTS: CT-angiogram performed on a 33-year-old female randomly revealed a new variant of gastroduodenal artery arising directly from the splenic artery along with other vascular aberrations. The latter were previously described in medical literature. CONCLUSION: High-quality preoperative imaging is crucial for identification of visceral artery variations, as those can technically modify the surgical or interventional procedure.

An anomalous origin of the gastrosplenic trunk and common hepatic artery arising independently from the abdominal aorta: a case report using MDCT angiography.

The authors describe a case of a 61-year-old female patient, which presented on multidetector computed tomographic (MDCT) angiography a gastrosplenic trunk (GST) and common hepatic artery (CHA) arose independently from abdominal aorta (AA). The GST arose from the anterior wall of the AA, at the level of upper edge of the L1 vertebral body. The left gastric artery (LGA) arose from the superior wall of the GST. The splenic artery (SA) continuous the path of GST. The CHA arose from the anterior wall of the AA, at the level of upper one third of the L1 vertebral body, at 15.3 mm above the origin of superior mesenteric artery (SMA). The incidence and developmental and clinical significance of this vascular variation is discussed with a detailed review of the literature.

Variantes anatómicas de la arteria esplénica / Anatomic variants of the splenic artery

Introducción: la arteria esplénica es uno de los tres ramos del tronco celiaco que irriga el bazo y emite ramos al estómago y al páncreas. Objetivo: determinar las características morfológicas de la arteria esplénica. Materiales y métodos: se realizó un estudio cuantitativo, longitudinal, prospectivo, observacional y descriptivo, en 26 bloques, provenientes de cadáveres sin cirugías abdominales, ni enfermedades hematológicas, en el Hospital Provincial Universitario "Celia Sánchez Manduley", de Manzanillo, provincia Granma. Los bloques fueron lavados, fijados y disecados por el método macroscópico directo. Resultados: La arteria esplénica se originó, mayormente en el tronco celiaco (88,46 %), su trayecto fue tortuoso en el 84,62 % de los bloques relacionándose por delante de la vena esplénica (80,77 %). Los ramos colaterales fueron más frecuentes en el segmento pancrático (54,96%). Las arterias gástricas cortas fueron los ramos colaterales mayormente emitidos (100 %). La longitud media de la arteria esplénica fue de 14,7 cm y su diámetro medio es de 0,86 cm. El número de arterias terminales tuvo una media de 6,04, mientras que las arterias gástricas cortas se emitieron en una media de 4,76. Conclusiones: la arteria esplénica presenta un patrón de variabilidad anatómica bajo en cuanto a su origen y trayecto, pero sus relaciones, forma de terminación, y ramos colaterales presentan grandes variantes a la norma anatómica (AU).

Introduction: the splenic artery is one of the three of the celiac trunk that irrigates spleen and emits branches to the stomach and the pancreas. Objective: to determine the morphologic characteristics of the splenic artery. Materials and methods: a descriptive, observational, prospective, longitudinal and quantitative study was carried out in 26 tissue samples without abdominal surgeries nor hematologic diseases in the Teaching Provincial Hospital "Celia Sánchez Manduley" of Manzanillo, Granma. The samples were washed, fixed and dissected using the direct macroscopic method. Results: the splenic artery originated, mostly, in the celiac trunk (88.46 %), its itinerary was tortuous in 84.62 % of the samples, linking before the splenic vein (80.77 %). Collateral branches were more frequent in the pancreatic segment (54.96 %). Short gastric arteries were the mostly emitted collateral branches (100 %). The average longitude of the splenic artery was 14.7 cm and its average diameter 0.86 cm. The number of terminal arteries showed an average of 6.04 while the short gastric arteries were emitted in an average of 4.76. Conclusions: the splenic artery has a low anatomic variability pattern according to its origin and itinerary, but its relations, ending form and collateral branches show big variants from the anatomic norm (AU).

Variantes anatómicas de la arteria esplénica / Anatomic variants of the splenic artery

Introducción: la arteria esplénica es uno de los tres ramos del tronco celiaco que irriga el bazo y emite ramos al estómago y al páncreas. Objetivo: determinar las características morfológicas de la arteria esplénica. Materiales y métodos: se realizó un estudio cuantitativo, longitudinal, prospectivo, observacional y descriptivo, en 26 bloques, provenientes de cadáveres sin cirugías abdominales, ni enfermedades hematológicas, en el Hospital Provincial Universitario "Celia Sánchez Manduley", de Manzanillo, provincia Granma. Los bloques fueron lavados, fijados y disecados por el método macroscópico directo. Resultados: La arteria esplénica se originó, mayormente en el tronco celiaco (88,46 %), su trayecto fue tortuoso en el 84,62 % de los bloques relacionándose por delante de la vena esplénica (80,77 %). Los ramos colaterales fueron más frecuentes en el segmento pancrático (54,96%). Las arterias gástricas cortas fueron los ramos colaterales mayormente emitidos (100 %). La longitud media de la arteria esplénica fue de 14,7 cm y su diámetro medio es de 0,86 cm. El número de arterias terminales tuvo una media de 6,04, mientras que las arterias gástricas cortas se emitieron en una media de 4,76. Conclusiones: la arteria esplénica presenta un patrón de variabilidad anatómica bajo en cuanto a su origen y trayecto, pero sus relaciones, forma de terminación, y ramos colaterales presentan grandes variantes a la norma anatómica (AU).

Introduction: the splenic artery is one of the three of the celiac trunk that irrigates spleen and emits branches to the stomach and the pancreas. Objective: to determine the morphologic characteristics of the splenic artery. Materials and methods: a descriptive, observational, prospective, longitudinal and quantitative study was carried out in 26 tissue samples without abdominal surgeries nor hematologic diseases in the Teaching Provincial Hospital "Celia Sánchez Manduley" of Manzanillo, Granma. The samples were washed, fixed and dissected using the direct macroscopic method. Results: the splenic artery originated, mostly, in the celiac trunk (88.46 %), its itinerary was tortuous in 84.62 % of the samples, linking before the splenic vein (80.77 %). Collateral branches were more frequent in the pancreatic segment (54.96 %). Short gastric arteries were the mostly emitted collateral branches (100 %). The average longitude of the splenic artery was 14.7 cm and its average diameter 0.86 cm. The number of terminal arteries showed an average of 6.04 while the short gastric arteries were emitted in an average of 4.76. Conclusions: the splenic artery has a low anatomic variability pattern according to its origin and itinerary, but its relations, ending form and collateral branches show big variants from the anatomic norm (AU).