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BACKGROUND: This report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis. CASE PRESENTATION: Left internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery. CONCLUSION: This case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

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OBJECTIVE: Reversed great saphenous vein (GSV) graft is widely used for revascularization in limb-sparing surgery for sarcoma invading great vessels. However, a mismatch in caliber between the reverse graft and cut end of the artery can threaten graft patency. Recently, we introduced the use of a venous valvulotome to allow nonreversed GSV graft. The purpose of this study was to evaluate the safety and versatility of this technique. DESIGN: We retrospectively compared long-term patency and limb salvage rates between nonreversed GSV and reversed GSV in patients undergoing limb-sparing surgery for sarcoma. METHODS: Thirty-seven patients were included, with 21 in the nonreversed GSV group and 16 in the reversed GSV group. Patient characteristics, surgical details, and complications were reviewed from the hospital records. The patency of the reconstructed vessels was assessed using contrast-enhanced CT or MRI. Statistical analyses, including Kaplan-Meier survival analysis, were employed for comparisons. RESULTS: The median follow-up was 38 months. Overall graft patency was 90.4% (19 of 21 patients) in the nonreversed GSV group and 81.2% (13 of 16) in the reverse GSV (RGSV) group. In the nonreversed GSV group, there was 1 case of graft occlusion each in the acute and chronic phases, but limb circulation remained intact and all limbs were spared. CONCLUSION: Nonreversed GSV grafting with valvulotome offers a safe and versatile alternative to reversed GSV grafts in limb-sparing sarcoma surgery. It eliminates the need for vein reversal and minimizes diameter mismatch, potentially expanding the indication for autologous revascularization to previously ineligible cases.

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OBJECTIVE: Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated. METHODS: This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates. RESULTS: Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications. CONCLUSIONS: Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

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Autologous vein is the optimal conduit for peripheral arterial bypass surgery, a standard recently highlighted by findings from the BEST-CLI trial. The Human Acellular Vessel is a novel biologic conduit produced using regenerative medicine technologies with structural and mechanical properties like a human blood vessel. Not yet approved by the United States Food and Drug Administration, the Human Acellular Vessel is being studied as an alternative bypass conduit in patients with peripheral arterial disease, vascular injury, and those in need of arteriovenous access for hemodialysis. This report describes and illustrates the technical aspects of intraoperative handling specific to the use of this new and innovative technology.

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Injuries to the common femoral artery (CFA) are usually associated with local fractures. Other common mechanisms of injury include intimal disruption, intramural hematomas, and subintimal fibrosis. Occlusions to the CFA may also result from blood clots or arterial emboli via blunt injury. Blunt trauma causing injury to the common femoral artery is exceedingly rare. Blunt injury to the CFA may be caused by "motor-scooter-handlebar syndrome." We present a unique case where the delayed diagnosis of such an injury led to acute renal failure, rhabdomyolysis, and prolonged morbidity.

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Introduction: Hepatic artery pseudoaneurysm (HAPA), a rare vascular complication that can develop after liver transplantation, is associated with a high mortality rate and graft loss. To salvage the liver graft, immediate revascularization, either through surgical or endovascular intervention, is required. However, currently there is no consensus on the optimal strategy. Here, we report three cases of liver transplant recipients diagnosed with HAPA and treated with immediate revascularization. In addition, we present an overview of HAPA cases described in the literature and make recommendations on how to treat this rare complication. Methods: All adults transplanted in our center between 2005 and 2021 were retrospectively reviewed. Literature search was done in PubMed for original studies between 1980 and 2021 reporting early hepatic artery (pseudo) aneurysm after liver transplantation requiring either surgical or endovascular intervention. Results: From a total of 1,172, 3 liver transplant patients were identified with a symptomatic HAPA and treated with immediate revascularization. HAPA occurred 73, 27, and 8 days after liver transplantation and was treated with immediate revascularization (two surgical and one endovascular intervention). Literature review identified 127 cases of HAPA. HAPA was managed with endovascular therapy in 20 cases and by surgical intervention in 89 cases. Overall reported mortality rate was 39.6%, whereas overall graft survival was 45.2%. Conclusion: Immediate surgical or radiological interventional excision and prompt revascularization to salvage liver grafts is feasible but still associated with a high mortality.

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Elastic laminae, an elastin-based, layered extracellular matrix structure in the media of arteries, can inhibit leukocyte adhesion and vascular smooth muscle cell proliferation and migration, exhibiting anti-inflammatory and anti-thrombogenic properties. These properties prevent inflammatory and thrombogenic activities in the arterial media, constituting a mechanism for the maintenance of the structural integrity of the arterial wall in vascular disorders. The biological basis for these properties is the elastin-induced activation of inhibitory signaling pathways, involving the inhibitory cell receptor signal regulatory protein α (SIRPα) and Src homology 2 domain-containing protein tyrosine phosphatase 1 (SHP1). The activation of these molecules causes deactivation of cell adhesion- and proliferation-regulatory signaling mechanisms. Given such anti-inflammatory and anti-thrombogenic properties, elastic laminae and elastin-based materials have potential for use in vascular reconstruction.

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Retroperitoneal liposarcoma (RPLS) is a rare but challenging neoplasm, which is frequently associated with iliac vessel invasion. We describe how we used a two-step arterial reconstruction technique to perform en bloc resection of a large RPLS involving the iliac arteries in three patients. A temporal long in situ graft bypass was established using a prosthetic vascular graft during dissection of the tumor. This bypass provided an unobscured surgical field, while maintaining blood flow in the lower limb during the operation. After removal of the tumor and washing out the abdominal cavity, the new prosthetic vascular graft of a suitable length was placed. No graft-related complications, including vascular graft infection or graft occlusion, occurred during the follow-up period. This novel technique appears to provide a safe and effective way to remove large RPLSs involving the retroperitoneal major vessels.

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Objective: The human acellular vessel (HAV) was evaluated for surgical bypass in a phase II study. The primary results at 24 months after implantation have been reported, and the patients will be evaluated for ≤10 years. Methods: In the present report, we have described the 6-year results of a prospective, open-label, single-treatment arm, multicenter study. Patients with advanced peripheral artery disease (PAD) requiring above-the-knee femoropopliteal bypass surgery without available autologous graft options had undergone implantation with the HAV, a bioengineered human tissue replacement blood vessel. The patients who completed the 24-month primary portion of the study will be evaluated for ≤10 years after implantation. The present mid-term analysis was performed at the 6-year milestone (72 months) for patients followed up for 24 to 72 months. Results: HAVs were implanted in 20 patients at three sites in Poland. Seven patients had discontinued the study before completing the 2-year portion of the study: four after graft occlusion had occurred and three who had died of causes deemed unrelated to the conduit, with the HAV reported as functional at their last visit. The primary results at 24 months showed primary, primary assisted, and secondary patency rates of 58%, 58%, and 74%, respectively. One vessel had developed a pseudoaneurysm deemed possibly iatrogenic; no other signs of structural failure were reported. No rejections or infections of the HAV occurred, and no patient had required amputation of the implanted limb. Of the 20 patients, 13 had completed the primary portion of the study; however, 1 patient had died shortly after 24 months. Of the remaining 12 patients, 3 died of causes unrelated to the HAV. One patient had required thrombectomy twice, with secondary patency achieved. No other interventions were recorded between 24 and 72 months. At 72 months, five patients had a patent HAV, including four patients with primary patency. For the entire study population from day 1 to month 72, the overall primary, primary assisted, and secondary patency rate estimated using Kaplan-Meier analysis was 44%, 45%, and 60% respectively, with censoring for death. No patient had experienced rejection or infection of the HAV, and no patient had required amputation of the implanted limb. Conclusions: The infection-resistant, off-the-shelf HAV could provide a durable alternative conduit in the arterial circuit setting to restore the lower extremity blood supply in patients with PAD, with remodeling into the recipient's own vessel over time. The HAV is currently being evaluated in seven clinical trials to treat PAD, vascular trauma, and as a hemodialysis access conduit.

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BACKGROUND: Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field. PURPOSE: In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call "one stay corner suture technique". CONCLUSIONS: We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the "one stay corner suture technique" can be easily applied in centers that perform LDLT.

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The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

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In the treatment of retroperitoneal sarcoma involving major vessels, complete resection with vascular reconstruction is challenging. We describe the case of a 72-year-old man who presented with 8 months of abdominal pain. Diagnostic workup revealed occlusion of the celiac trunk and the origin of the superior mesenteric artery due to a soft tissue sarcoma. Radical resection of the tumor and vessels was performed. Guided by intraoperative angiography, arterial reconstruction was performed without mesenteric ischemia. All arterial margins were negative. At the 6-year follow-up, the patient was alive with no evidence of recurrence.

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Aims: The study aimed to review the use of synthetic grafts (SGs) and autologous vein grafts (AVGs) in visceral arterial reconstruction (VAR) in chronic visceral ischaemia. Methods: Systematic review methodology was employed. Results: Six studies were included (218 patients and 281 vessels). Two studies had data about AVG only, 3 had data about SG only and 1 had both AVG and SG data. Three studies reported outcomes for AVG (117 patients and 132 vessels revascularized). One-year primary patency was 87% (95% CI 71%, 97%). Graft thrombosis rate was 6% (95% CI 0%, 16%). Pooled stenosis rate at one-year was 11% (95% CI 1%, 28%). The 30-day (n = 96), one-year (n = 72) and 5-year mortality (n = 30) were 0%, 0% and 12%, respectively. Four studies reported outcomes for SGs (106 patients and 147 vessels). The pooled primary patency at one year was 100% (95% CI 99%, 100%). Pooled primary 5-year patency rate was 88% (95% CI 69%, 100%). There was no graft infection in 2 of the 3 studies. Overall pooled percentage of graft thrombosis and stenosis at one year was 0%. Jimenez et al. (2002) reported one graft thrombosis at 20 months and graft stenosis in 2 patients at 46 and 49 months. Illuminati et al (2017) reported graft thrombosis in 2/24 patients at 22 and 52 months. Thirty days, one-year and 5-year mortality was 1% (95% CI 0%, 6), 7% (95% CI 0%, 20%) and 39% (95% CI 11%), respectively. Conclusion: Patency was better with SG compared with AVG. Mortality was higher in the SG group. Graft dilatation does occur with vein grafts, but in this review no intervention was found necessary. Poorly designed studies, incomplete reporting and absence of morbidity and mortality indices preclude emphatic conclusions.

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OBJECTIVE: To study topographic changes of femoral triangle arteries during open revascularization of the lower limbs. MATERIAL AND METHODS: A retrospective study included 30 men aged 59.6±3 years with atherosclerotic femoropopliteal occlusion and chronic lower limb ischemia IIb-III stage according to the Pokrovsky-Fontaine classification. All patients underwent open reconstructive interventions. Ten patients underwent above-knee femoropopliteal replacement with a synthetic prosthesis, 10 patients - above-knee femoropopliteal bypass with a synthetic prosthesis, 7 patients - above-knee femoropopliteal bypass with autologous vein, 3 patients - below-knee femoropopliteal bypass with autologous vein. Control group consisted of 30 healthy mean aged 60±2 years. Ultrasound was carried out using the Esaote My Lab Alfa scanner (3-12 MHz linear transducer and 3-5 MHz convex transducer). RESULTS: In healthy volunteers, deep femoral artery always arose from common femoral artery under the angle ≤30° in all cases (20° - 93.3% of cases, 30° - 6.7% of cases). In patients with previous surgical treatment, angle of deep femoral artery varied from 35 to 80°. After femoropopliteal bypass grafting with autologous vein, angle of deep femoral artery varied from 35 to 45° (35° - 8 patients, 40° - 1 patient, 45° - 1 patient). After femoropopliteal bypass grafting with a synthetic prosthesis, angle of deep femoral artery increased up to 40-50° (40° - 2 patients, 50° - 8 patients). In case of previous femoropopliteal replacement with a synthetic prosthesis, angle of deep femoral artery increased up to 70-80° (70° - 7 patients, 75° - 2 patients, 80° - 1 patient). CONCLUSION: Normally, angle of deep femoral artery does not exceed 30°. Open reconstructive surgery on femoropopliteal arteries increases this value from 30° to 80°. Minimal changes are observed after femoropopliteal bypass grafting with autologous vein.

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OBJECTIVE: Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction. METHODS: Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses. RESULTS: Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups. CONCLUSIONS: Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.

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Background: In the case of complicated kidney transplantation, when the accessory artery is severed, the main task is to decide whether to restore renal blood flow and which method should be used. In this report, we present a case of kidney transplantation with vascular reconstruction using an ovarian vein as an interposition graft between a larger branch of the main renal artery and the lower polar artery which was severed during kidney explantation. Case summary: Kidney transplantation using an ovarian vein was performed for a 34-year-old woman with end-stage renal disease on 1 April 2020 in the Hospital of Lithuanian university of health sciences (LUHS) Kaunas Clinics. A lower accessory renal artery was severed during kidney explantation. As the ovarian vein of the donor remained and matched the diameter of the severed vessel, it was decided to use it as an insertion between the main renal artery and the accessory renal artery of the inferior pole. The cold ischemic time was 770 min and the warm ischemic time was 37 min. A month after transplantation, the patient's condition and daily urine output were normal and the serum creatinine level decreased rapidly. Fifteen months after the surgery, the function and structure of the transplant remained normal and there was no evidence of serious vascular complications on CT scans. This is the first case where graft function was verified after transplantation using three-dimensional CT angiography. Conclusions: If an inferior polar artery is severed, vascular reconstruction must be performed to preserve the function of the graft. Usually, the gonadal vein is available during donor nephrectomy; therefore, it can be explanted without additional difficulties or incisions. Although we have not reported any complications, further studies are recommended on the long-term outcomes of this alternative approach for the reconstruction of short renal arteries.

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Pediatric nonaortic arterial aneurysms are uncommon diagnoses and can be affiliated with underlying conditions, which include neurofibromatosis I, Ehlers-Danlos type IV syndrome, Kawasaki disease, Marfan syndrome, and Loeys-Dietz, polyarteritis nodosa, as well as Klippel-Trenauny syndrome. The standard of care has been early surgical excision and arterial reconstruction when indicated. This report details a case of recurrent brachial artery aneurysm in a 2-year-old boy despite multiple attempts at excision and reconstruction. Such recurrences were seen as rapidly as 3 months postoperatively. Ultimately, a Gore-Tex conduit was used to reinforce a reversed saphenous vein graft repair. There has been no evidence of recurrent disease during the 18-month follow-up period.

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BACKGROUND: Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included 'split liver transplantation', 'arterial reconstruction', and 'machine perfusion'. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction. RESULTS: A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis. CONCLUSION: Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.

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To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

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INTRODUCTION: Extended pancreatectomy for initially unresectable locally advanced (URLA) pancreatic carcinoma (PC) often requires combined arterial resection/reconstruction. By limiting candidate arterial inflow after combined resection of the celiac arterial system over a long distance, great saphenous vein graft (GSVG) is an alternative conduit for obtaining non-anatomical arbitrary arterial inflow. PRESENTATION OF CASE: A 66-year-old woman was diagnosed with URLA pancreatic head carcinoma involving the region from the celiac axis (CA) to the common hepatic and proximal splenic artery (SA). She received 10 courses of modified FOLFIRINOX followed by concurrent chemoradiotherapy including S1 with favorable response. The duration of disease control and normalization of serum carbohydrate antigen 19-9 (CA19-9) exceeded 10 months, and conversion surgery was planned. Extended pancreaticoduodenectomy (PD) required concomitant resection of the CA to the proper hepatic and SA. The dual arterial reconstructions involved a GSVG interposition from the abdominal aorta to the distal SA to preserve the entire stomach, and from the mesenteric second jejunal artery to the right hepatic artery. The patient achieved pathological R0 resection with a histological response of Evans grade IIB. DISCUSSION: Reconstruction of the distal SA with GSVG in extended PD enabled preservation of the subtotal stomach and distal pancreas, even when the root of the CA was transected. CONCLUSION: Multiple arterial reconstructions using GSVG might be useful in extended pancreatectomy to preserve visceral organs, offer better quality of life in terms of oral intake and nutritional status, and control blood glucose than after total pancreatectomy concomitant with subtotal gastrectomy.