J Hepatobiliary Pancreat Sci (2019) 26:281–291
DOI: 10.1002/jhbp.636
REVIEW ARTICLE
Gastroduodenal artery: single key for many locks
Gunjan S. Desai  Prasad M. Pande
Published online: 19 June 2019
© 2019 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Gastroduodenal artery (GDA) commonly arises
from common hepatic artery, a branch of celiac axis. It
holds a unique anatomical position that connects the foregut
and midgut due to its intimate communications with foregut
and midgut arterial supply. Its numerous anatomical
variations have a significant impact on planning and
performance of hepatopancreaticobiliary (HPB) surgery. Its
close relation to the first part of duodenum, common bile
duct and head of pancreas makes it susceptible for
inadvertent bleeding during or after surgery, or due to
various HPB pathologies. Also, a large number of vascular
interventions rely on GDA and its branches. Careful
preoperative planning is the key and a detailed knowledge
and awareness of its variant anatomy is of paramount
importance, be it liver resections, liver transplant, biliary
and pancreatic resections and pancreatic transplant or
transarterial procedures involving these arteries. GDA can
also be a cause of gastrointestinal hemorrhage due to true or
pseudoaneurysms and anatomy has significant implications
on its management. The article provides a succinct review
on relevance of GDA anatomy and variations and
highlights that preoperative planning and intraoperative
awareness of variations is the key to performance of safe
HPB surgery and interventions.
Keywords Aneurysm Celiac artery
 
Pancreaticoduodenectomy
Introduction
A thorough knowledge of arterial anatomy and its varia-
tions is a key prerequisite for safe hepatopancreaticobil-
iary (HPB) surgery [1, 2]. So frequent are arterial
variations that it is impossible to consider any one
G. S. Desai (✉) P. M. Pande

Department of Gastrointestinal Surgery, Lilavati Hospital and
Research Center, Mumbai, Maharashtra 400050, India
e-mails: desaigunjan526@gmail.com, dsshlsh@gmail.com
anatomical description as normal [3]. A comprehensive
understanding of these variations is indispensable for
planning liver resections, liver transplant, pancreas surgery
or transplant, biliary resections and reconstruction [1, 3,
4]. Though some variations are not clinically significant
and do not affect organ function, others need careful pre-
operative planning for intra-operative identification and/or
modification in surgical technique to preserve or recon-
struct the vessel [2, 3]. Gastroduodenal artery (GDA) is
one of the key vessels that one encounters during perfor-
mance of HPB surgeries or interventions. A detailed
review of its common and variant anatomy will help diag-
nostic and interventional radiologists as well as surgeons
in planning complex HPB procedures [1, 3, 4].
History
Vesalius in 1534 labelled GDA as ramus duodenitis, later
described as GDA by Haller in 1745 [5]. Meckel in 1832
described the principle variant anatomy of GDA [5].
Wilkie described the supraduodenal and the retroduodenal
arteries and the vessel is now called Wilkie’s artery [5, 6].
Finally, Michels gave the most comprehensive description
of celiac axis (CA) and its branches in 1966 [6]. GDA
and its branches have not been a topic of detailed study
in itself across published literature and its branches have
been named differently by different researchers, thereby
creating difficulties in reviewing the scarce literature on
this vessel [7].
Diagnostic modalities and standard terminology
Cadaveric models and conventional angiography were
commonly used methods for studying arterial anatomy.
However, thin section, dynamic contrast enhanced com-
puted tomography (CT) with submillimeter voxel size, and
availability of excellent post-acquisition processing tools
like minimum intensity projection, volume rendering, and
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multiplanar reformation has replaced conventional angiog-
raphy for diagnostic evaluation of GDA [1, 3].
A deviation from what is regarded as normal anatomy
such that it affects the function of the area or organ it sup-
plies is termed as a malformation, whereas, when it does
not directly affect the function, it is called a variation.
The variation in arterial anatomy can be with regard to its
origin, number, course, branches and the organs supplied
[3, 4]. An artery is called a replaced artery (labeled by a
prefix “r”) when it is the only arterial supply to an organ
but has an anomalous origin. However, an artery with
anomalous origin in addition to the artery from its normal
origin is called accessory (labeled by a prefix “a”) [3, 4].
CA is considered to have an ambiguous anatomy when
common hepatic artery (CHA) is absent or when there is
a persistent anastomotic channel connecting CHA to CA
and superior mesenteric artery (SMA). CHA is an arterial
trunk which must contain GDA and at least one segmental
hepatic artery, regardless of its origin and anatomical
course [1]. Kapoor [8] suggested renaming GDA as gas-
troduodenopancreatic (GDP) trunk to highlight this impor-
tant vessel supplying the distal part of the stomach, first
and second part of duodenum, ampulla, head of pancreas,
and omentum. However, the term GDP trunk has not yet
been standardized.
Embryology
The key to understanding why variations occur and how
they anatomically appear lies in the developmental
Table 1 Possible sites of origin of gastroduodenal artery in published literature and its frequency
Study (year)
Lipshutz (1917) [14]
Michels (1953) [15]
Huu et al. (1976) [16]
VanDamme (1993) [17]
Covey et al. (2002) [18]
Daseler (2005) [19]
Rawat (2006) [20]
Petrella et al. (2007) [21]
Chitra (2009) [22]
Younan et al. (2016) [23]
Patil et al. (2017) [24]
Chen et al. (2018) [25]
Younan et al. (2016) [23]
Slaba and Assaf (2018) [26]
J Hepatobiliary Pancreat Sci (2019) 26:281–291
pathway of abdominal aorta and its branches. On the 17th
day of embryonic life, hemangioblasts aggregate adjacent
to endoderm in splanchnic extraembryonic mesoderm of
the vitelline duct. On the 18th day vessels start forming in
splanchnic intraembryonic mesoderm. Over the next
3 days, paired dorsal aorta form along the length of the
embryo [9, 10]. From days 21 to 28, segments of dorsal
aorta between T4 and L4 fuse to form a unique median
vessel, which is descending aorta. This vessel gives rise
to intersegmental lateral somatic arteries, lateral splanch-
nic arteries and ventral splanchnic arteries. The ventral
splanchnic arteries are known as vitelline arteries. Vitel-
line arteries are segmental, paired, and symmetrical, and
are interconnected through longitudinal anastomosis at dif-
ferent levels. As the embryo grows, regression, remodel-
ing, and transformation of these arteries and their
longitudinal anastomosis lead to persistence or disappear-
ance of segments at different levels, which causes the
development of variations of abdominal arteries [10, 11].
The 10th ventral splanchnic artery becomes the CA, 13th
becomes the SMA and 22nd becomes the inferior mesen-
teric artery [11]. Depending on this remodeling process,
various variations arise [10–12].
Origin of GDA
The most common origin of GDA is from CHA. Beyond
origin of GDA, CHA is termed proper hepatic artery
(PHA) which gives rise to right hepatic artery (RHA) and
left hepatic artery (LHA) [8, 13]. The configuration at
Site of origin Frequency
Common hepatic artery 92.3%
Celiac trunk 3.6%
Celiac trunk or superior mesenteric artery 2.5%
Superior mesenteric artery Case report
Common hepatic artery 75%
Superior mesenteric artery 2%
Left hepatic artery 11%
Right hepatic artery 8%
Aorta 0.33%
Celiac trunk 0.2%
Right hepatic artery or left hepatic artery –
Celiac trunk or superior mesenteric artery 6.74%
Celiac trunk Case report
Superior mesenteric artery Case report
Inferior pancreaticoduodenal artery Case report
Splenic artery Case report
J Hepatobiliary Pancreat Sci (2019) 26:281–291
origin of GDA from CHA can also be variable. CHA can
trifurcate into RHA, LHA, GDA or can give rise to RHA
first and then trifurcate into LHA, GDA and right gastric
artery (RGA). Pentafurcation of CHA has been described
where CHA gives rise to RHA, LHA, GDA, RGA and
artery to segment IV of liver [2]. An aGDA has not been
reported in literature. In a meta-analysis of CA variations
which included 12,000 cases from 36 studies, there was
no mention of a replaced GDA (rGDA) [2, 7]. Many
other studies have identified frequency of variations in ori-
gin of rGDA, summarised in Table 1 [14–26]. The vari-
ous sites of origin of rGDA are shown in Figure 1. The
most common site of origin of rGDA is CA.
Course and relations of GDA
GDA arises from CHA, posterosuperior to first part of
duodenum (D1) usually at a distance of 2.5–3.0 cm from
pylorus. The GDA usually arises 1–2 cm above D1 and
travels caudally behind D1 anterior to common bile duct
(CBD). In 20% of cases, its origin can be retroduodenal
[27]. The GDA divides D1 into two segments: a 35 mm
long proximal intraperitoneal segment, the duodenal bulb,
and a distal retroperitoneal segment 15 mm in length [28,
29]. GDA is not accompanied by a vein [8]. The course
of GDA is divided into an intraepiploic suprapancreatic
segment and an interduodenopancreatic segment [27].
The relation between GDA and CBD has been studied
in detail. The Prudhomme classification describes the
coronal relationship and divides it into four types. Type 1
(63%) is the most common, where GDA origin is to the
left of CBD and moves away from CBD as it traverses
behind D1. In type 2 (20%), origin of GDA is to the left
of CBD, and courses very close to it without crossing
CBD as it goes behind the duodenum. In type 3 (14%),
Le
artery
Common hepa
Right hepa
artery artery
Aorta
Common bile Celiac axis
duct
1.5 cm
3.5 cm Splenic artery
Gastroduodenal Prepyloric vein
artery of Mayo
Replaced common
hepa ery
Superior
mesenteric
artery
Fig. 1 Possible sites of origin of gastroduodenal artery (sites of ori-
gin are marked with blue dot)
283
Le
artery
Right hepa
artery Common
hepa
artery
Common bile
duct
III
IV II
Gastroduodenal I
artery
Fig. 2 The configuration types I, II, III and IV of gastroduodenal
artery in relation to common bile duct as per the Prudhomme classi-
fication [30]
GDA arises from CHA to the left of CBD and crosses it
anteriorly from left to right behind D1. In type 4 (3%),
CHA crosses CBD from left to right and then gives rise
to GDA on the right aspect of CBD. This GDA remains
on the right side of the CBD behind D1 [30]. These types
are schematically shown in Figure 2. The distance
between GDA and CBD in sagittal plane is 3 mm at the
superior border of duodenum, 4 mm in the middle of the
posterior surface of the duodenum and 5 mm at the infe-
rior border of the duodenum [27].
In 57–60% of cases, there is 5–10 mm of intercholedo-
choduodenal pancreatic glandular tissue between GDA
and CBD, known as duodenal tubercle or omental tuber-
cle of Wiart. This tissue separates GDA from CBD along
its course. Below D1, GDA travels between duodenum
and pancreas in the duodenal gutter of Wiart [27, 31].
Studies have shown that a rGDA originating from SMA
arises below the neck of the pancreas and runs anterior to
the neck of pancreas, whereas a rGDA originating from a
rCHA from SMA arises below the neck of pancreas and
courses posteriorly or sometimes even through the pancre-
atic parenchyma and very rarely anterior to the pancreas
[23, 24].
Variations in branching pattern of GDA
In its most common configuration, the intraepiploic supra-
pancreatic part of GDA first gives rise to one or more
supraduodenal arteries of Wilkie, within 3 mm of its ori-
gin [5]. The supraduodenal arteries can also arise from
RGA in 13% of cases, as well as from posterior superior
pancreaticoduodenal artery (PSPDA) occasionally [28,
32]. The first major branch of GDA is PSPDA, which
usually arises above the duodenum within 3 mm to 1 cm
284
from the origin of GDA. PSPDA, however, can also arise
from CHA, rCHA in 3% of cases each, as a common
trunk with anterior superior pancreaticoduodenal artery
(ASPDA) which is then called the superior pancreatico-
duodenal artery (SPDA) in 5–7% of cases and occasion-
ally can arise from PHA or RHA [30, 33, 34]. After its
origin from GDA, PSPDA crosses from left to right in
front of CBD above D1 and then courses around the CBD
behind the head of the pancreas and crosses it from right
to left. In this part, there is a thin rim of pancreatic tissue
between PSPDA and CBD [34, 35]. PSPDA is one of the
most important vessels supplying the ampulla. It gives
dorsal and ventral branches to the lower end of CBD and
ampulla, along with branches from the retroduodenal
artery [36, 37]. It can also give rise to a replaced or acces-
sory cystic artery in 1% of cases, supraduodenal artery,
retroduodenal artery, aRHA and RGA in 1% of cases. The
right branch of dorsal pancreatic artery (DPA) may occa-
sionally anastomose with PSPDA [34, 35, 38, 39]. It
finally anastomoses with posterior inferior pancreaticoduo-
denal artery (PIPDA), which arises from SMA to form the
posterior pancreatic arcade. This arcade lies farther from
the duodenum as compared to the anterior arcade and sup-
plies the head of pancreas and duodenum [34, 35].
Beyond PSPDA, GDA gives three to five retroduode-
nal arteries, which supply the duodenum. The principal
blood supply to the D1 is via the supraduodenal and retro-
duodenal arteries [5, 36]. At the lower border of D1,
GDA gives rise to its terminal branches, commonly the
right gastroepiploic artery (RGEA) and ASPDA. Occa-
sionally, the terminal branch is SPDA, which then divides
into ASPDA and PSPDA [40, 41]. This SPDA was previ-
ously known as posterior pancreaticoduodenal artery of
Michel or retroduodenal artery of Shapiro [41]. ASPDA
runs caudally in the interduodenopancreatic groove and
descends anterolaterally within 1 cm of the second part of
the duodenum. It forms the anterior pancreatic arcade near
the posterior surface of the uncinate process of pancreas
by its anastomosis with anterior inferior pancreaticoduode-
nal artery (AIPDA), commonly arising from SMA [8, 42].
ASPDA is usually larger than PSPDA and in 90% of
cases arises from GDA, whereas PSPDA arises in 75–
80% of cases from GDA. At papilla, ASPDA courses cau-
dally within 1–2 mm from CBD and is very close to it at
this point [35, 43]. Occasionally RGEA can arise from
ASPDA or SMA. ASPDA can also receive branches from
TPA, retroduodenal artery and the right root of prepancre-
atic arcade of Kirk [34–36].
RGEA, immediately after its origin, gives infrapyloric
branches that supply D1 and pylorus, and then course
along the greater curvature of the stomach to anastomose
with the left gastroepiploic artery (LGEA), a branch of
splenic artery in most cases. This communication is also
J Hepatobiliary Pancreat Sci (2019) 26:281–291
known as the Arc of Barkow. The infrapyloric arteries, 8–
18 in number, can be paired anterior and posterior or sin-
gular branches [32, 44]. Apart from these branches, GDA
can give a direct communicating collateral channel to
SMA and form the Arc of Buhler. This collateral channel
can also arise from the CA [11]. Besides these, DPA and
TPA can occasionally arise from GDA, ASPDA or RGEA
[32, 35, 36, 44]. The classical branches of GDA and its
variant branches are shown in Figure 3 [3, 8, 18, 45–49].
The most commonly identified variant branch from GDA
is accessory cystic artery seen in 2.6% of cases [45].
Replaced cystic artery from GDA is reported from 1 in 21
cases in one study to 1 in 200 cases in the published liter-
ature [46, 47]. Other variant branches include right gastric
artery, aRHA or rRHA, aLHA or rLHA, and occasionally,
a hepatic segment IV branch [3, 8, 18, 48, 49].
Clinical implications of the variant anatomy of GDA
A thorough knowledge of the normal and variant anatomy
of GDA and its branches, along with their relations to the
surrounding structures, is of utmost importance in plan-
ning various upper gastrointestinal and HPB surgeries.
These especially include hepatic and pancreatic surgeries
that require vascular resection and/or reconstruction, hep-
atic or pancreatic transplant surgeries, and management of
post-surgical hemorrhagic complications [1–4]. Abdominal
vascular procedures – whether open or endovascular –
routinely done for thoraco-abdominal aneurysms and
celiac artery stenoses (CAS) also require pre-operative
GDA mapping. With the increasing usage of interven-
tional radiology, procedures like transarterial embolization
(TAE), transarterial chemoembolization (TACE), transarte-
rial radioembolization (TARE), placement of hepatic
artery infusion (HAI) pump, administration of HAI
chemotherapy, and management of upper gastrointestinal
bleed are increasingly being performed, which require
knowledge of variant vascular anatomy [7, 50, 51]. GDA
aneurysms can arise as a result of various HPB and upper
gastrointestinal tract diseases or intrinsic vascular abnor-
malities, and need a well planned endovascular or surgical
approach to avoid ischemic complications to the organs
supplied by it, especially when variant arterial anatomy is
present [52, 53]. All these critical surgical steps are dis-
cussed below with key focus on GDA with its variations.
Pancreatic surgery
GDA identification and ligation is one of the key steps
during pancreaticoduodenectomy (PD). This begins with
accurate preoperative identification of anatomical course
J Hepatobiliary Pancreat Sci (2019) 26:281–291 285

Fig. 3 The classical and variant Gastroduodenal artery

branches of GDA as described in NORMAL VARIANT
literature [3, 8, 18, 45–49] branches Supraduodenal artery Right gastric artery branches
Posterior superior Cys ery
pancrea oduodenal artery
Accessory cys ery
Posteior inferior Posterior arcade Accessory or replaced
pancrea oduodenal artery right hepa ery
Retroduodenal artery Accessory or replaced
Anterior superior le ery
pancrea oduodenal artery Hepa t IV branch
Anterior Dorsal pancrea ery
Anterior inferior arcade
pancrea oduodenal artery Transverse pancrea ery
Kirk’s prepancrea Arc of Buhler to SMA
arcade
Kirk’s prepancrea Anterior superior Transverse
Right branch of
pancrea oduodenal artery pancrea
dorsal pancrea ery arcade
artery
Kirk’s prepancrea
Posterior superior Cys ery,
arcade
Right gastroepiploic artery pancrea oduodenal artery retroduodenal
Arc of Barkow artery,
Le astroepiploic artery accessory right hepa ery

Right gastroepiploic Transverse pancrea

artery artery

and variations of GDA [23, 24]. It is important to rule out
CAS at this stage on imaging or endoscopic ultrasound
(EUS) if it is being performed. CAS is seen in 4–20% of
cases in the general population, whereas its incidence is
2.0–7.6% in patients undergoing PD [54]. CAS may be
due to extrinsic (eccentric) compression by median arcuate
ligament (MAL) or peri-arterial ganglionic tissue or an
intrinsic (concentric) stenosis due to atherosclerosis or due
to neoplastic disease, acute or chronic arterial dissection,
vascular injury or an external compression by an inflamed
pancreas. In the presence of CAS, hepatic arterial supply
is fed by SMA through pancreaticoduodenal arcades via
GDA. In these cases, GDA ligation during PD can lead to
irreversible ischemic damage to liver, D1 and biliary sys-
tem [55–57]. An important EUS sign of CAS is the pres-
ence of a prominent GDA or ASPDA (normal arterial
diameter of GDA is 4  0.3 mm which increases to
7 mm and/or ASPDA, which is normally <4 mm
increases to 6 mm) [58].
Pre-operatively identified intrinsic stenosis may be trea-
ted by endovascular balloon dilatation with or without
stent placement. If the patient is already planned for sur-
gery such as PD, surgical management options for CAS
can be combined with PD [55, 59]. These include transec-
tion of MAL and peri-arterial tissue, arterial bypass from
aorta or SMA to CHA beyond GDA origin using autolo-
gous great saphenous vein or external jugular vein or a
prosthetic polytetrafluoroethylene (PTFE) graft, or arterial
reimplantation. Surgical procedures are preferred in the
patients who are already undergoing surgery for another
indication, since antiplatelet therapy after endovascular
procedures leads to higher bleeding risk during surgery
[55, 56, 59].
Arterial variations frequently warrant an artery-first
approach for PD. An infracolic SMA first approach is pre-
ferred when rGDA arises from SMA or from rCHA. The
infracolic SMA first approach is performed by lifting the
transverse mesocolon followed by dissection of SMA and
superior mesenteric vein (SMV) at its root over the fourth
part of the duodenum. The dissection then proceeds along
the anterior wall of SMA to its origin from aorta. By this
approach, the rGDA or rCHA would be identified first
and preserved. This approach also helps in identification
of rGDA arising from IPDA which is a branch of SMA.
In these cases, IPDA may need ligation beyond the origin
of GDA [23, 24].
Once GDA is identified during PD, the next important
step is to evaluate for CAS. Irrespective of its preopera-
tive assessment, Bull’s test is a mandatory step before
ligation of GDA [56]. This test is performed by first feel-
ing the pulsation of PHA before clamping GDA, followed
by GDA clamping and re-assessing the pulsation in PHA
by palpation or intraoperative color doppler ultrasound. If
the pulsation or flow diminishes, GDA cannot be ligated
without intraoperative assessment for CAS, followed by
surgical intervention if needed [55, 56]. The most com-
monly performed intervention is transection of MAL and
surrounding tissue, which resolves it in most cases.
Another option is performance of GDA-preserving PD
with preservation of one of the pancreaticoduodenal
286
arcades. Though GDA preservation has been found to be
safe in periampullary cancers, peripancreatic arcade
preservation is not a good option in periampullary and
pancreaticoduodenal malignancy [55–57, 59].
GDA preservation has also been suggested when pylorus
preserving PD is performed since blood supply to the duo-
denal stump is preserved [60]. The incidence of post pan-
createctomy hemorrhage is also lower, especially in cases
with pancreatico-enteric anastomotic leak. During GDA
preservation in these cases, ASPDA and PSPDA are ligated
whereas GDA and RGEA are preserved. This is feasible in
periampullary cancers but not in pancreatic head adenocar-
cinoma [60, 61]. Another rare but clinically significant situ-
ation requiring GDA preservation is intraoperative injury to
PHA during PD. This needs repair or reconstruction to pre-
vent biliary leaks and strictures as well as hepatic ischemia.
The options include primary repair, interposition of autolo-
gous great saphenous or gonadal vein or transposition of
native arteries such as splenic artery, RGEA or GDA, or
using prosthetic Gore Tex graft [62, 63]. GDA transposi-
tion to the proximal CHA stump can be done to reconstruct
a rCHA traversing through pancreatic parenchyma needing
resection during PD or to reconstruct a CHA resected dur-
ing PD by anastomosis of transposed GDA to CA [64].
Besides PD, GDA preservation is a key part of distal
pancreatectomy with CA resection (DP-CAR or the modi-
fied Appleby procedure). DP-CAR is performed in pancre-
atic body tumors involving CA and the origin of CHA
proximal to the origin of GDA. The procedure relies on
the blood supply to PHA from GDA through the pre-
served pancreaticoduodenal arcade. This collateral channel
can be made the dominant supply to biliary system, liver
and pancreatic head by embolization of celiac origin and
left gastric artery if deemed necessary [65, 66].
In postoperative period in PD, late post PD hemorrhage
– defined as hemorrhage seen after 24 h of surgery – is
seen in 3–5% of cases and is associated with a mortality
rate of 16–22% [67, 68]. Erosion of GDA stump pseudoa-
neurysm is the most common cause and it occurs after a
median interval of 7–13 days after surgery. It is more com-
mon with pancreatico-enteric anastomotic leak [68, 69]. It
is commonly preceded by a sentinel bleed which warrants
CT angiography. Once the bleeding is manifest, conven-
tional angiography with embolization or covered stent
placement is the treatment of choice and is successful in
most cases. Surgical ligation is reserved for failure of
embolization [67, 69, 70]. Theoretically, this complication
can be prevented by protection of skeletonized GDA stump
by a pedicled falciform ligament wrap or an omental wrap.
In practice, however, this wrap has not been shown to be
effective in reducing the incidence of post-PD hemorrhage
in retrospective studies. There is an ongoing multicentric
randomized controlled trial labeled “PANDA” trial to
J Hepatobiliary Pancreat Sci (2019) 26:281–291
assess the efficacy of this wrap in reducing the incidence
of this bleed. Results of this trial are awaited [70].
Apart from PD, GDA is also important in other pancre-
atic surgeries [71–73]. Bleeding from GDA, ASPDA or
one of its branches can be very severe and difficult to
control in pancreatic necrosectomy for walled off pancre-
atic necrosis involving the head and neck of pancreas.
Inflamed, friable tissue and limited access may make
hemostasis exceedingly difficult, and intraoperative inter-
ventional radiology support may be needed to control
bleeding by embolization or covered stent placement [71].
While performing duodenum preserving pancreatic head
resection for chronic pancreatitis known as the Beger pro-
cedure or its modifications by Frey or Berne, it is impera-
tive to preserve at least the posterior pancreatic arcade
between PSPDA and PIPDA, thereby preserving the blood
supply to second part of duodenum and ampulla [72].
Another situation is during cadaver pancreatic graft
retrieval as a part of multivisceral retrieval. Here, GDA is
divided at its origin from CHA and the rest of the CHA-
PHA axis goes with the liver graft. In this situation, after
SMA re-implantation to provide blood supply to the duo-
denopancreatic complex, blood supply predominantly
depends on IPDA. However, when IPDA is high rising or
variant, it may be transected inadvertently during the pro-
curement surgery. In this case, blood supply gets compro-
mised as it remains fully dependent on DPA and splenic
artery. If the blood flow from these vessels is not enough,
GDA or RGEA have been reconstructed independently
above the donor SMA to recipient’s common iliac artery
using an external iliac jump graft from donor GDA or
RGEA to recipient’s common iliac artery, thereby provid-
ing the blood supply to the transplanted organs [73].
Biliary surgery
When the cystic artery or the accessory cystic artery arises
from GDA or SPDA, it will be, as a rule, anterior to the cys-
tic duct, known as transposition of cystic duct and cystic
artery [74]. The cystic artery will thus be the first structure
encountered during Calot’s triangle dissection in laparo-
scopic cholecystectomy and can lead to bleeding during
surgery if not identified. Nearly one-third of biliary injuries
during laparoscopic cholecystectomies have concomitant
vascular injuries. When CHA is inadvertently clipped, col-
lateral channels from GDA through SMA provide blood
supply to liver and biliary tree via the peripancreatic arcade.
However, when PHA is injured/clipped, this collateral route
is blocked. In these cases, collateral circulation from acces-
sory or replaced hepatic arteries from GDA, RGA-LGA
anastomotic channel or RGEA-LGEA channel provides the
blood flow to the hepatobiliary system. All of these
J Hepatobiliary Pancreat Sci (2019) 26:281–291
collaterals develop connecting GDA, SMA, CA proximal to
the injured artery to falciform ligament artery, RHA or
LHA distal to the injured artery via phrenic, gastric, esopha-
geal, intercostal and/or splenic arterial branches [74, 75].
In hilar cholangiocarcinoma, arterial resections can be
performed to achieve R0 resection. PHA repair/reconstruc-
tion after resection is important to avoid biliary complica-
tions as the biliary system relies solely on hepatic arterial
blood supply. In these cases, primary repair can be per-
formed when the arterial resection is less than 1 cm in
length. However, for length between 1 and 2 cm, GDA
can be flipped on its origin after resecting its distal end
and then anastomosed to the distal end of the PHA. For
defect >2 cm, a bridge reconstruction using GDA graft to
achieve a tension free anastomosis is preferred as it will
be an in-situ reconstruction option in these cases and the
diameter of GDA also matches well with the PHA [76].
Liver transplant
Arterial diameter <0.2 cm is an absolute contraindication
for living donor related liver transplant, whereas 0.2–
0.3 cm arterial diameter is a relative exclusion criterion.
Smaller arterial diameters are more commonly seen with
variant arterial anatomy. Studies show a higher rate of
post transplant complications especially hepatic artery
thrombosis (HAT) and graft loss after orthotopic liver
transplant in presence of variant anatomy especially for to
smaller arterial diameter in these cases [48, 77, 78].
GDA steal syndrome is an important phenomenon in rela-
tion to liver transplant. It is the less common of the arterial
steal syndromes (ASS), which occurs in 3.2–6.0% of liver
transplants. Stenosis of the graft artery, increased portal
blood flow and decreased hepatic arterial blood flow after
liver transplantation as well as increased intra-hepatic arterial
resistance are possible inciting factors. It can result in ele-
vated liver enzymes, cholestasis, HAT and impaired graft
function [79, 80]. ASS can be diagnosed postoperatively by
CT angiography and colour doppler when above features are
seen. Intraoperatively, colour doppler is performed to evalu-
ate arterial flow patterns. If the hepatic arterial flow is dimin-
ished after reimplantation, the vessel responsible for steal
can be ligated. Postoperatively diagnosed ASS can be man-
aged by surgical ligation or use of arterial conduits from
suprarenal or supraceliac aorta to hepatic artery [80].
GDA aneurysms and gastrointestinal hemorrhage
Arteries involved in upper gastrointestinal hemorrhage
include splenic artery in 40% of cases, GDA in 30%, pan-
creaticoduodenal artery in 20%, and gastric and hepatic
287
artery in 5% and 2%, respectively [81, 82]. Common
causes for GDA pseudoaneurysms include chronic pancre-
atitis, liver cirrhosis, fibromuscular dysplasia, polyarteritis
nodosa, trauma, septic emboli and post surgery, especially
PD. Other causes include cholecystectomy, peptic ulcer
disease, vascular interventions and liver transplantation.
Intrinsic vascular disorders such as Takayasu’s arteritis,
Marfan syndrome, Ehlers-Danlos syndrome, Polymyalgia
rheumatica and neurofibromatosis are associated with true
GDA aneurysms and account for 8% of total cases of
GDA aneurysms [53, 83, 84]. Up to 60% of GDA aneur-
ysms coexist with pancreatitis. In chronic pancreatitis the
incidence of aneurysms is up to 10% where the most
common artery involved is the splenic artery and GDA
pseudoaneurysms are seen in 1.5% of cases [43].
GDA pseudoaneurysms are more common in the age
of 50–58 years and males are more commonly affected
with male to female ratio of 4.5:1. However, true aneur-
ysms of GDA affect both genders equally. Its mean size
is 3.6 cm. It most commonly presents with intraabdominal
rupture (in up to 60% of cases) with hemetemesis, melena
and hypovolemic shock [53]. Risk of rupture is indepen-
dent of size of the aneurysm [84]. Presence of coexisting
visceral aneurysms is seen in 18% of cases and presence
of CAS is seen in nearly one-third cases [85]. Other com-
mon symptoms include epigastric pain radiating to back,
pulsatile abdominal mass, gastric outlet obstruction and
obstructive jaundice. Rare presentations include hemobilia
or hemosuccus pancreaticus. Mortality associated with
rupture is up to 30% [83, 84].
Abdominal ultrasound has a low sensitivity of 50% for
diagnosis of GDA aneurysm. CT angiography also has a
low sensitivity of 67%. Conventional angiography is the
gold standard diagnostic test, which can also be therapeu-
tic with TAE [53]. For all accidentally discovered nonrup-
tured cases or ruptured aneurysm with hemodynamic
stability, treatment with coil embolization or covered stent
graft deployment is the preferred treatment. Embolization
can also be done with cyanoacrylate glue, gelatin foam or
ethanol sclerosant. Only for hemodynamically unstable
patients with ruptured GDA aneurysm, surgery is pre-
ferred with intraoperative options of ligation, aneurysmor-
raphy or bypass. Even in these cases, endovascular
treatment is preferred if feasible. During surgery, vascular
reconstruction after ligation or resection is necessary only
if there is a coexisting CAS [83–85]. A case has also been
described where IPDA pseudoaneurysm with CAS was
managed by retropancreatic aorta to GDA 6 mm–4 mm
tapered PTFE graft to revascularize CA followed by
aneurysm resection [57].
Due to anatomic proximity of GDA to the posterior
wall of D1, bleeding from posterior duodenal ulcers pre-
dominantly involve GDA. The incidence has decreased
288 J Hepatobiliary Pancreat Sci (2019) 26:281–291

Table 2 Various hepato-pancreato-biliary surgeries/procedures and role of gastroduodenal artery

Surgery/procedure Key steps involving gastroduodenal Surgical/interventional management options
artery (GDA)

Pancreas
Pancreatico-duodenectomy Preoperative
Celiac axis stenosis
Abnormal arterial anatomy
• rGDA from SMA/rCHA/IPDA
Intraoperative
Bull's test positive
GDA preserving surgery
GDA stump
Postoperative
GDA pseudoaneurysm
Pancreatic necrosectomy Hemorrhage – GDA or its branch
Beger procedure Arcade preservation
Multivisceral retrieval High rising or variant
for pancreatic graft IPDA – transected inadvertently
Biliary surgery
Laparoscopic Accessory cystic artery from
cholecystectomy GDA or SPDA
Vasculobiliary injury
Hilar cholangiocarcinoma Arterial resection and
reconstruction
Liver transplant
Living donor Arterial diameter <0.2 cm
GDA steal syndrome
Interventions
Radioembolization Hepatofugal flow in GDA
Hepatic artery Hepatofugal flow in GDA
chemotherapy/pump
• Endoscopic ultrasound sign - prominent GDA (≥7 mm)
and/or ASPDA (≥6 mm)
• Endovascular/surgical management
An infracolic SMA first approach is preferred
• Management of celiac axis stenosis
• GDA preserving surgery
• Positive Bull's test
• Pylorus preserving pancreaticoduodenectomy for periampullary
cancers
• Proper or common hepatic artery resection and reconstruction
using GDA
• Modified Appleby procedure
Falciform ligament or omental wrap
Angio-embolization
Surgical control or intraoperative angioembolization
Preserve at least the posterior pancreatic arcade
GDA reconstruction to recipient common iliac artery above the
SMA anastomosis will preserve blood supply to implanted
pancreas
Transposition of cystic duct and artery to be kept in mind
Collaterals are based on site of injury - proximal or distal to
GDA: implications on management
Proper hepatic arterial resection >1 cm, GDA is useful for reconstruction
Contraindication
Intra-operative – ligate GDA post-operative – arterial conduits
from aorta to hepatic artery or GDA ligation
Inject beyond GDA origin
Place catheter tip beyond GDA origin or temporary GDA
embolization

due to widespread use of proton-pump inhibitors, and the
bleeds that do occur are managed endoscopically. How-
ever, if surgery is required, control of bleed is achieved
by three point ligation of the vessel with the help of a U-
stitch. A rare case of arteriovenous fistula between GDA
and a branch directly draining into portal vein has been
described. The patient presented with pain in upper
abdomen and a murmur in the right upper abdomen. He
had undergone gastrectomy in the past, which was the
probable cause for the arteriovenous fistula. The fistula
was managed by surgical ligation. Other options include
excision or repair of the fistula or prosthetic graft place-
ment [86].
HPB vascular intervention and GDA
TAE, TACE, TARE and HAI chemotherapy and HAI
pump placement are few of the other procedures where
arterial anatomy from CHA, GDA, PHA as well as their
branches is the key to planning. This arterial tree is also
increasingly being used for endovascular procedures [7,
50, 51]. When angiography prior to TARE show a GDA
with hepatofugal flow, identified by an intermittent opaci-
fication of anterior and posterior pancreaticoduodenal
arcade during angiography, GDA occlusion can be
avoided during the procedure and the radionuclide must
be injected downstream to the origin of GDA. If GDA
J Hepatobiliary Pancreat Sci (2019) 26:281–291
Common hepa
1 artery
Aorta
Common bile Celiac axis
duct
Splenic artery
Gastroduodenal
artery 2 mind this vessel and its branches while planning and
Replaced common
hepa ery
Superior
mesenteric
artery
3 Conflict of interest None declared.
Fig. 4 Surgical approach to GDA. 1. Start dissection from common
hepatic artery or proper hepatic artery to origin of GDA and proceed
downwards behind the duodenum; 2. Start dissection along the right
gastroepiploic artery to its origin from GDA and then upwards
behind the duodenum along GDA; 3. Infracolic SMA first approach
for rGDA from SMA or rCHA from SMA
gets occluded, it can result in gastroduodenal ulceration or
acute pancreatitis [50].
In some patients, for HAI chemotherapy, the catheter
tip cannot be positioned beyond the origin of GDA into
the PHA. In these cases, the direction of blood flow in
GDA is to be ascertained. If the flow is antegrade towards
the pancreas, therapeutic embolization of GDA with a
temporary occlusion agent like gelfoam is preferred to
prevent significant amounts of chemotherapeutic agent
from reaching stomach, duodenum or pancreas, which can
precipitate toxicity. The benefit of using temporary occlu-
sion material is that the GDA would be preserved for sub-
sequent surgical insertion of a HAI pump for prolonged
chemotherapy. The variant arterial anatomy also influ-
ences the HAI pump placement [51].
The surgical/interventional importance of GDA in vari-
ous HPB procedures is summarized in Table 2. It clearly
shows how the vessel plays an intricate role in the various
HPB procedures and planning of these surgeries therefore
needs to be done keeping in mind, the anatomy and varia-
tions of this important artery. The surgical approach to
GDA can be from CHA below or from RGEA above
whereas the surgical approach to rGDA is preferably by
infracolic SMA first approach and these approaches are
depicted in Figure 4.
Conclusion
The variant anatomy of GDA and its branches has impor-
tant implications on planning and performance of a multi-
tude of HPB surgeries and interventions. A thorough
anatomical delineation is a crucial part of pre-operative
289
planning. Presence of rGDA, GDA aneurysms and pseu-
doaneurysms, bleeding from these aneurysms or from GDA
stump and hepatic vascular interventions are a few scenar-
ios where the above knowledge is essential. At the same
time, GDA, due to its unique anatomical position, can fre-
quently be used as a collateral supply or a conduit to the
hepatobiliary vasculature. It is hence imperative to bear in
embarking on any major surgery in this anatomical region
as preoperative planning is the key to safe HPB surgery.
Author contributions Collecting data, analysis of data, preparing
the initial draft of the manuscript, critical revision of the manuscript
for intellectual content, technical support, material support, study
supervision: Gunjan Desai. Critical revision of the manuscript for
intellectual content, technical support, material support, study
supervision and revision of draft: Prasad Pande.
Compliance with ethical standards The publication was performed
in accordance with international agreements (World Medical Association
Declaration of Helsinki “Ethical Principles for Medical Research
Involving Human Subjects,” amended in October 2013, www.wma.net).
Informed consent Informed consent was obtained from the patient
for this publication.
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