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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 02, January 2015, Pages 23-33

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www.ijhbr.com ISSN: 2319-7072

Original article:

Arterial arcades of Pancreas and their variations

Chavan NN*, Wabale RN**

[*Assistant Professor, ** Professor and Head]

Department of Anatomy, Rural Medical College, PIMS, Loni , Tal. Rahata, Dist. Ahmednagar, Maharashtra, Pin - 413736.

Corresponding author: Dr Chavan NM

Abstract:

Introduction: Pancreas is a highly vascular organ supplied by number of arteries and arterial arcades which provide

blood supply to the organ. Arteries contributing to the arterial arcades are celiac and superior mesenteric arteries

forming anterior and posterior arcades. These vascular arcades lie upon the surface of the pancreas but also supply

the duodenal wall and are the chief obstacles to complete pancreatectomy without duodenectomy. Knowledge of

variations of upper abdominal arteries is important while dealing with gastric and duodenal ulcers, biliary tract

surgeries and mobilization of the head of the pancreas, as bleeding is one of the complications of these surgeries.

During pancreaticoduodenectomies or lymph node resection procedures, these arcades are liable to injuries.

Material and methods: Study was conducted on 50 specimens of pancreas removed enbloc from cadavers to study

variations in the arcade.

Observation and result: Anterior arterial arcade was present in 98% specimens and absent in 2%. It was formed by

anterior superior pancreaticoduodenal artery(ASPDA) and anterior inferior pancreaticoduodenal artery(AIPDA) in

92%, Anterior superior pancreaticoduodenal artery (ASPDA), Anterior inferior pancreaticoduodenal artery (AIPDA)

and Right dorsal pancreatic artery (Rt.DPA) in 2%, Anterior superior pancreaticoduodenal artery (ASPDA) only in

2%, Anterior superior pancreaticoduodenal artery (ASPDA) and Posterior inferior pancreaticoduodenal artery

(PIPDA) in 2%, Arcade was absent and Anterior superior pancreaticoduodenal artery (ASPDA) gave branches in

2%. Similarly posterior arcade also showed variations with presence in only 98% specimens.

Conclusion: Wide range of statistical records of arterial supply of pancreas, show that it is an organ that lies in three

peripancreatic interlocking arterial circles with varying degree of variations making it difficult to differentiate and

classify normal, variant and anomalous. It shows that developmental probabilities and possibilities associated with

two pancreatic buds approaching each other, enlarging and invading into a meshwork of blood vessels are many.

Key words: Arcades, variations, surgical importance

Introduction

Pancreas is second largest of digestive glands of the

human body having glandular tissue of two different

types for accomplishing two different functions. The

major part is an exocrine gland secreting enzymes for

digestion of ingested food and the other is an

endocrine part for glucose homeostasis and

gastrointestinal motility.

Pancreas is an organ that develops at the boundary

between foregut and midgut. The area of foregut is


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supplied by the celiac trunk and the midgut by

superior mesenteric artery. This explains the

description of classical anatomy of the area that the

blood supply of second part of duodenum and the

head of pancreas originates from several arteries that

spring from the celiac axis and the superior

mesenteric artery.1 The pancreaticoduodenal arcades

which are located anterior and posterior to the

pancreatic head, are major source of blood supply of

pancreatic head and the second part of the duodenum.

Extensive interference with the pancreaticoduodenal

arcades in the course of a 95% pancreatectomy may

compromise the blood supply of the duodenum

because of the shared blood supply of the duodenum

and pancreatic head.2 In addition, because the

duodenojejunal flexure and the first part of the

jejunum may derive their blood supply from branches

of the inferior pancreaticoduodenal artery or the

pancreaticoduodenal arcades, ligation of these vessels

in the course of a resection may render the proximal

jejunum ischemic.3 Typically, the posterosuperior

pancreaticoduodenal artery arises from the

gastroduodenal artery and passes to the right, anterior

to the common bile duct, forming a major source of

blood supply to common bile duct. This relation is of

surgical importance in case of operation involving

mobilization of the lower end of the common bile

duct.3

There are variations in this arcades like; it may be

doubled or tripled. The posterior arcade may also

anastomose with an aberrant right hepatic artery from

the superior mesenteric artery and also there are

variations in the origins of arteries forming arcade.

So the study was conducted to study the pattern of

arterial arcades supplying pancreas and the variations

in arterial arcades of pancreas and to compare the

findings with available literature to establish a data

for this region.

Material and methods

The study was carried out on 50 specimens removed

enbloc from the cadavers, available in the department

of Anatomy of Rural Medical College, Loni,

Maharashtra. The approval of the Institutional Ethical

and Research Committee was sought before

beginning the study.

Inclusion criteria: Formalin embalmed adult

cadavers with normal anatomy of pancreas

irrespective of sex were used in this study. These

were the cadavers meant for utilization by first year

medical students for routine dissection.

Exclusion criteria: The cadaveric specimens with

obvious abdominal pathology or operative procedures

were excluded from the study.

The enbloc removal, along with pancreas included

the duodenum, the spleen, the related part of the

abdominal aorta and portal vein. The dissection

necessary to study the arterial supply of different

parts of the pancreas was carried out. A hand lens

was used wherever necessary. Each and every

specimen thus dissected was documented with the

help of line drawing and photograph.

After removal and cleaning the dissected specimen

all parameters such as origin of arteries forming

arcade, distance of arcade from duodenum, number

of arcades and number of branches were noted. The

data collected was analyzed and expressed as

percentage. Wherever required the data was subjected

to statistical analysis. Other incidental observations in

the course of study were recorded and discussed in

the light of existing literature.

Abbreviations - (AA- Abdominal Aorta ,CT- Celiac

trunk ,CHA- Common Hepatic Artery, HA- Hepatic

Artery Proper, GDA- Gastroduodenal Artery ,


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ASPDA- Anterior Superior Pancreaticoduodenal

Artery PSPDA-Posterior Superior

Pancreaticoduodenal Artery, RGEA- Right

Gastroepiploic Artery ,IPDA- Inferior

Pancreaticoduodenal Artery , AIPDA- Anterior

Inferior Pancreaticoduodenal Artery, PIPDA-

Posterior Inferior Pancreaticoduodenal Artery,

APAr- Anterior Pancreaticoduodenal

Arcade/Anterior arcade, PPAr- Posterior

Pancreaticoduodenal Arcade /Posterior arcade)

Observation

1. Anterior Pancreaticoduodenal Arcade (APAr):

Two major arterial arcades were identified i.e.

anterior and posterior. Anterior arcade is formed by

anterior superior pancreaticoduodenal and anterior

inferior pancreaticoduodenal arteries and posterior

arcade is formed by posterior superior

pancreaticoduodenal and posterior inferior

pancreaticoduodenal arteries, mostly.

Anterior arcade was present in 98% (49/50)

specimens and absent in 2%.

Arteries of origin are shown in table 1 (figure 1 and

Photograph 1,2,3,4).

Table 1: Showing origin of Anterior Pancreaticoduodenal Arcade

Origin No. %

Anterior superior pancreaticoduodenal artery (ASPDA) and Anterior inferior

pancreaticoduodenal artery (AIPDA)

46/50 92%

Anterior superior pancreaticoduodenal artery (ASPDA), Anterior inferior

pancreaticoduodenal artery (AIPDA) and Right dorsal pancreatic artery (Rt.DPA)

1/50 2%

Anterior superior pancreaticoduodenal artery (ASPDA) only 1/50 2%

Anterior superior pancreaticoduodenal artery (ASPDA) and Posterior inferior

pancreaticoduodenal artery (PIPDA)

1/50 2%

Arcade absent and Anterior superior pancreaticoduodenal artery (ASPDA) gives

branches

1/50 2%

Total 50/50 100%


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Figure 1: Showing arteries of origin for Anterior Pancreaticoduodenal Arcade

ASPDA, AIPDA and Rt.DPA 1/50 (2%) ASPDA only1/50 (2%)

(Photograph 1) (Photograph 2)

ASPDA & PIPDA 1/50 (2%) Arcade absent &ASPDA gives branches 1/50 (2%).


Distance of arcade from duodenum: The distance of arcade from duodenum ranged from 0(at

pancreaticoduodenal junction) to 3 cm with mean 0.54 and standard deviation of 0.68.

In 20 specimens the arcade was hidden by pancreatic tissue (40%).

Number of Arcade: In all specimens only single arcades were found.

Number of branches by arcade: Average number =8; Range =6 - 10

2. Posterior pancreaticoduodenal arcade (PPAr):

This arcade was present in 98% and absent in 2% specimens. Arteries of origin are shown in table 2 (Figure 2 and

Photograph 5,6,7,8,9,10)

ASPDA

AIPDA

RT. DPA

ASPDA

PIPDA

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Table 2: Showing origin of Posterior Pancreaticoduodenal Arcade

Origin No. %

Posterior superior pancreaticoduodenal artery (PSPDA) and Posterior inferior

pancreaticoduodenal artery (PIPDA)

43/50 86%

Posterior superior pancreaticoduodenal artery (PSPDA), Posterior inferior pancreaticoduodenal

artery (PIPDA) and extra branch from superior mesenteric artery (SMA)

2/50 4%

Posterior superior pancreaticoduodenal artery (PSPDA),Posterior inferior pancreaticoduodenal

artery (PIPDA) and extra branch from abdominal aorta (AA)

1/50 2%

Posterior superior pancreaticoduodenal artery (PSPDA) only 1/50 2%

Anterior inferior pancreaticoduodenal artery (AIPDA) and Posterior superior pancreaticoduodenal

artery (PSPDA)

1/50 2%

Arcade absent and Right hepatic artery (RHA) gives branches 1/50 2%

Posterior superior pancreaticoduodenal artery (PSPDA), Posterior inferior pancreaticoduodenal

artery (PIPDA) and Anterior inferior pancreaticoduodenal artery (AIPDA)

1/50 2%

Total 50/50 100%

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Figure 2: Showing arteries of origin for Posterior Pancreaticoduodenal Arcade

PSPDA, PIPDA and Extra branch PSPDA, PIPDA and extra branch from

from SMA 2/50 (4%). AA 1/50 (2%).


PSPDA only forms arcade 1/50 (2%). PSPDA and AIPDA 1/50 (2%).


PPAr is absent and RHA gives PSPDA, PIPDA and AIPDA 1/50 (2%).

branches 1/50 (2%)


PSPDA

PIPDA

EXTRA BRANCH

FROM SMA EXTRA BRANCH

FROM AA

PSPDA

PIPDA

AIPDA

PSPDA

RHA

AIPDA

PIPDA PSPDA

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Distance from duodenum-The distance of arcade

from duodenum ranged from 0 (at pancreat-

icoduodenal junction) to 2.9 cm, with a mean 1.36

and standard deviation of 0.52. There was a

statistically significant difference (p value< 0.05)

between the mean distance of anterior arcade and

mean distance of posterior arcade from

pancreaticoduodenal junction.

Number of arcades - arcade was single in all cases.

Number of branches by arcade: Average number

=7; Range = 6 - 10.

Discussion

Anterior Pancreaticoduodenal Arcade (APAr): An

arcade of an artery supplying branches to anterior

surface of both duodenum and head of pancreas is

present in 98% cases in this study; same was present

in all cases studied by Kimura W et al.16 In 92%

cases this arcade is formed by anterior superior

pancreaticoduodenal artery and anterior inferior

pancreaticoduodenal artery; whereas same is noted in

all cases studied by Kimura W et al.16In 40% cases

the lower 2/3rd arcade was found to be partly

embedded within pancreatic tissue; this occurrence

finds no mention anywhere in the available literature.

On an average we found eight branches arising from

anterior arcade supplying only the duodenum.

Smaller delicate branches arising from the arcade

sunk directly into substance of pancreas (Photograph

No.11).

Photograph 11: Anterior arcade embedded within

pancreatic tissue.

Posterior Pancreaticoduodenal Arcade (PPAr):

Another arcade artery supplying posterior surface of

duodenum and pancreas is present in 98% of cases in

this study, in all the cases studied by Michel NA et

al9, and 88% of cases studied by Kimura W et

al.16Variable origin of the two source arteries for

arcade was noted in this study; arcade formation by

posterior superior pancreaticoduodenal artery and

posterior inferior pancreaticoduodenal artery was

seen in 86% cases. Similar combination is seen in

78% by Van Damme et al8, and in 88% cases studied

by Kimura W et al.16

Location of this arcade was farther away from

duodenum as compared to anterior arcade. On an

average we found seven branches arising from

posterior arcade supplying duodenum (2nd part) along

with common bile duct. Smaller delicate branches

arising from the arcade sunk into posterior surface of

head of pancreas

There are anastomoses at all levels of pancreas. This

extensive arterial network of the pancreas is an

important source of collateral blood supply in cases

of occlusion of celiac axis, superior mesenteric or

splenic arteries. The existence of individual

differences, development of arterial–arterial

anastomosis asks for obligatory preoperative

supraselective angiography which enables insight

into distribution of blood vessels.17

It is into this meshwork of vessels the pancreatic buds

sprout from two opposite sides i.e. dorsal and ventral

of the second part of duodenum (Picture No.1).

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Picture 1: Development of Blood supply of Gastrointestinal tract and Pancreas18

Dorsal bud sprouts and enlarges on the left side of

network of vessels in the dorsal mesentery of

duodenum. Hence after rotation and fixation of the

duodenal loop the blood vessels for body and tail of

pancreas are seen to be located on posterior surface

only. Ventral bud along with bile duct and network of

vessels on its both side rotates and fuses with dorsal

bud, hence the presence of blood vessels in the form

of arcade is seen on both surfaces of head of

pancreas. In a general way, this explains the

existence of three peripancreatic, interlocking arterial

circles; the variations among the pancreatic vessels in

different individuals; and the varying calibers of

vessels.14 Thus pancreatic arteries may have variable

origins as well as variable caliber. Arteriography can

outline most of the arteries of the pancreas, so it is

advisable to obtain preoperative angiograms to

provide more orderly intraoperative identification and

control of the arterial blood.

Summary and conclusion

All the arteries supplying different parts of pancreas

were studied with respect to their origin, termination,

length, and parts of pancreas supplied. We found that

pancreas is an organ that lies in three peripancreatic

interlocking arterial circles with varying degree of

variations often making it difficult to differentiate

and classify normal, variant and anomalous.

• All the arteries supplying arcades of

pancreas were found to have a variable

origin, length and termination.

• Different studies on the arterial supply of

pancreas came up with a wide range of

statistical records. No one particular reason

can satisfactorily explain occurrence of such

variations in arteries supplying pancreas.

• These studies are from different region of

the world. Food type, bodily habitus, and the

habitat vary from region to region leading to

variation in morphology of organs

associated with alimentary system and

consequent rearrangement of vessels.

• The reason for variations being found in the

same geographical region may lie in the

many developmental probabilities and

possibilities associated with two pancreatic

buds approaching each other, enlarging and

invading into a meshwork of blood vessels.

• One Should have precise knowledge

regarding the anatomy of the pancr-

eaticoduodenal region ( pancreaticoduodenal

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arteries) which provide blood to the

duodenum.

• There is a need to preserve the

pancreaticoduodenal arteries to avoid

duodenal necrosis

• Preservation of the pancreaticoduodenal

arteries would provide a better supply of

blood to the duodenal wall.

• Distance of posterior arcade from

duodenojejunal junction was found to be

significantly more than the distance of

anterior arcade which is most probably due

to presence of common bile duct between

posterior arcade and duodenum.

• In 40% specimens the arcade was hidden by

pancreatic tissue.

One thing that became apparent in this study was

need to include a larger sample size in view of the

quantum and spectrum of variations that we came

across in a relatively small sample size. Study in a

larger sample size was not possible due to constraints

with respect to time and availability of specimens for

study.

A thorough search of literature did not yield any

publication related to study of arteries of pancreas

from our region. This was probabaly the first attempt

in our region to study and document arteries of

pancreas in detail. The knowledge of the vascular

anatomy of pancreatic region is an important

prerequisite for planned surgical intervention. The

awareness of the existing vascular anomalies

enhances the insight of any region and thus the

chances of successful outcome.

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