A selective strategy for celiac trunk non-reconstruction in visceral debranching hybrid surgery for abdominal aortic...

To explore the feasibility and clinical value of a novel strategy involving selective non-reconstruction of the celiac trunk based on pancreaticoduodenal arterial arch collateralization during visceral zone debranching hybrid surgery for abdominal aortic aneurysm (AAA).

We report a case of a 68-year-old male patient with a 52 mm paravisceral AAA (infradiaphragmatic, without thoracic involvement) involving the origins of the visceral arteries. Preoperative CTA demonstrated well-developed pancreaticoduodenal arterial arch collateralization. An innovative strategy was adopted: only the superior mesenteric artery and bilateral renal arteries were revascularized, with selective non-reconstruction of the celiac trunk. The hybrid surgical procedure is described in detail including patient positioning, incision, graft type, operative time, blood loss, EVAR landing zone, and access site. The technical advantages of this strategy and the postoperative imaging validation results were analysed.

In this case, classic four-vessel revascularization was simplified to a three-vessel procedure, reducing surgical difficulty and avoiding dissection posterior to the pancreas as well as pancreas-related complications. Total operative time was 275 min, estimated blood loss was 450 mL, and no intraoperative transfusion was required. Postoperative CTA revealed satisfactory perfusion of the celiac trunk system, homogeneous enhancement of the liver parenchyma and splenic parenchyma (no evidence of splenic infarction), robust retrograde filling of the pancreaticoduodenal arterial arch and gastroduodenal artery, absence of endoleak, and patency of the bypass grafts. Postoperative endoscopic examination showed normal gastric mucosa, and serum amylase/lipase levels remained within normal limits. The patient had no postprandial symptoms, and bowel function returned on postoperative day 2.

Selective non-reconstruction of the celiac trunk via pancreaticoduodenal arterial arch collateralization represents an innovative strategy for visceral zone debranching in hybrid surgery for AAA. This strategy simplifies the procedure and reduces surgical trauma through a "subtraction" approach while ensuring adequate visceral perfusion. The strategy reduces surgical risk by avoiding pancreas-related complications, shortening operative time, and reducing warm hepatic ischemia time. Postoperative CTA serves as a core tool for validating the efficacy of collateral compensation. Long-term imaging surveillance is essential to monitor for late complications including pancreaticoduodenal arch aneurysm formation and Type II endoleak.