ª Springer Science+Business Media, LLC 2007
Abdominal Published online: 3 January 2008
Imaging
Evaluation of the vascular supply to regions
of the pancreas on CT during arteriography
Yusuke Sakuhara,1 Yoshihisa Kodama,2 Daisuke Abo,1 Yu Hasegawa,1
Tadashi Shimizu,1 Tokuhiko Omatsu,1 Tamotsu Kamishika,1 Yuya Onodera,1
Satoshi Terae,1 Hiroki Shirato1
1
Department of Radiology, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo,
Hokkaido 060-0838, Japan
2
Department of Radiology, Teine Keijinkai Hospital, Sapporo, Japan
Abstract
Background: To evaluate the vascular supply of regions
of the pancreas on computed tomography (CT) during
arteriography with selective catheterization.Methods:
Thirteen patients were included. In each patient we per-
formed conventional arteriography followed by CT
during arteriography of each of the arteries: the superior
mesenteric artery (SMA), gastroduodenal artery (GDA),
and splenic artery (SPA). The regions of the pancreas
that were most enhanced on CT during arteriography
were considered to be the areas receiving the greatest
infusion of blood from the selected artery.Results: In all
13 patients, the uncinate process, the superior head, and
the tail of the pancreas were predominantly supplied by
the SMA, GDA, and SPA, respectively. The inferior
head of the pancreas was predominantly supplied by the
SMA in five patients, the GDA in nine patients, and both
the SMA and GDA in one patient. The body of the
pancreas was predominantly supplied by the SMA,
GDA, and SPA in seven, two, and ten patients, respec-
tively.Conclusions: The uncinate process predominantly
infused by the SMA, the superior head by the GDA, and
the tail by the SPA. The patterns of the vascular supply
of the inferior head and the body vary from patient to
patient.
Key words: Pancreas—Vascular supply—CT during
arteriography—Variation—Dorsal pancreatic artery
Correspondence to: Yusuke Sakuhara; email: YRB03514@nifty.com
Abdom Imaging (2008) 33:563–570
DOI: 10.1007/s00261-007-9342-x
Transarterial drug delivery using the technique of tran-
sarterial catheter insertion has been applied to pancreatic
diseases. As a diagnostic technique, selective arterial
calcium stimulation and hepatic venous sampling has
been attempted for localization of insulinomas [1–5]. As
a catheter-directed therapy technique, transcatheter
arterial infusion therapies have been applied to pancre-
atitis [6–8] and advanced pancreas cancer [9–17] as an
adjunct to more conventional therapies.
The principal feeding arteries of the pancreas are the
superior mesenteric artery (SMA), gastroduodenal artery
(GDA), and splenic artery (SPA), and the blood supply
from these three main arteries is supplemented by smaller
arterial branches such as the inferior pancreaticoduode-
nal artery (IPDA), dorsal pancreatic artery (DPA), great
pancreatic artery, and transverse pancreatic artery.
However, the precise relation between these arteries and
the various regions of the pancreas has not been estab-
lished.
Homma et al. reported that the induction of arterial
hemodynamic change using superselective embolization
would be useful to increase the efficiency of intra-arterial
chemotherapy for the primary pancreatic tumor [15].
Tanaka et al. reported that CT during arteriography is
useful to evaluate the drug distribution of intra-arterial
chemotherapy for advanced pancreatic cancer [17]. They
also showed that the celiac side of the pancreas is sup-
plied from the celiac artery (CA) and the SMA side of the
pancreas is supplied from the SMA and IPDA in a
majority of patients. These two studies showed that
many arteries feed the pancreas, leading to wide varia-
tions in the arterial blood distribution, and that it is
therefore crucial to obtain accurate information on the
blood distribution in the pancreas before initiating
564 Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography

transarterial drug delivery therapy. Sometimes arteriog-
raphy cannot provide sufficient information on the blood
distribution in the pancreas; in such cases, CT can pro-
vide a detailed and accurate assessment [17].
CT during arteriography which involves CT scanning
with the selective arterial infusion of contrast material
using a conventional arteriography technique has been
shown to be useful in assessing vascular supply to hepatic
nodules [18, 19]. In this technique, the most enhanced
area on the CT images is regarded as the area receiving
the greatest supply of blood from the infused artery. We
applied this technique to the evaluation of vascular
supply to the pancreas by selective arterial infusion
of contrast material into various arteries during CT
scanning.
The DPA originates from several arteries, i.e., the
CA, CHA, SPA or SMA [20]. This artery leads mainly to
the transverse pancreatic artery and perfuses the central
part of the pancreas. Therefore, we considered that the
question of which artery the DPA branches from plays
an important role in blood distribution in the pancreas.
The purpose of this study was to depict variations in
arterial blood distribution in the pancreas by CT during
arteriography.
Materials and methods
We retrospectively reviewed our database for patients
with pancreatic diseases who had undergone arteriog-
raphy between September 1999 and August 2005 at our
institution. The inclusion criterion for this retrospective
review was that CT during arteriography with selective
catheterization was performed during the period of
conventional arteriography. Patients were excluded if
(1) they had an apparent pancreatic anomaly; or (2)
arteriography showed a large vascular obstruction
or severe stenosis in the CA, SMA, GDA or SPA due
to the disease for which the angiography had been
indicated.
Our database search identified 17 patients with pan-
creatic diseases who received both conventional arteri-
ography and CT during arteriography. Four of the 17
patients were excluded from this analysis because of
annular pancreas (n = 1), severe celiac arterial invasion
by pancreatic cancer (n = 1), or severe arterial stenosis
or obstruction induced by median arcuate ligament
compression (n = 2). Thus 13 patients were included in
this retrospective study. There were eight males and five
females, and the mean ± standard deviation of age was
58.1 ± 19.3 years. Eleven patients were suspected to
have tumors of the pancreas, one had chronic pancrea-
titis, and one had tumor-forming chronic pancreatitis
(Table 1).
Our institutional review board approved this retro-
spective study and all patients had provided their
written informed consent to undergo the procedure and
to contribute the data on their clinical outcomes to
future medical researches. The whole procedure of
arteriography and CT scanning was performed using an
Angio-CT System (Advantx ACT; GE Yokogawa
Medical, Tokyo, Japan), which consists of a single
detector helical CT scanner combined with a digital
fluoroscope. This system obviated the need for patient
transfer from the angiography room to the CT room,
and thus avoided the potential dislocation of the cath-
eter tip from the vessel.
The patient was catheterized via the femoral artery
with a 4- or 5-French (Fr) sheath, and an angiographic
catheter was successively inserted into the SMA, CA,
GDA, and SPA, after which angiography was per-
formed using non-ionic iodine contrast media (300 mgI/
ml). During selective arteriography via the SMA, GDA,
and SPA, CT scanning was also performed using a slice

Table 1. Characteristics of patients: diseases, main supplying arteries to the regions of the pancreas evaluated by CT during arteriography and the
artery which is branching the dorsal pancreatic artery in 13 patients
Age Sex Diseases Main supplying arteries to the regions of the pancreas evaluated by CT during DPA branching from
arteriography

Uncinate process Inferior head Superior head Body Tail

33 M Insulinoma SMA SMA SMA/GDA SMA/GDA/SPA SPA SMA

68 M Adenocarcinoma SMA GDA GDA GDA SPA SPA
63 F Adenocarcinoma SMA GDA GDA SMA/SPA SPA SPA
67 M Adenocarcinoma SMA SMA GDA SPA SPA SPA
61 F Adenocarcinoma SMA SMA GDA SMA/SPA SPA SPA
78 M Adenocarcinoma SMA SMA GDA SPA SPA CA
75 M Adenocarcinoma SMA GDA GDA SMA/SPA SPA SMA
21 F Chronic pancreatits SMA GDA GDA GDA/SPA SPA CHA
71 M Tumor-forming chronic SMA GDA GDA SMA SPA SMA
pancreatitis
65 M Insulinoma SMA GDA/SMA GDA SPA SPA SPA
70 F Adenocarcinoma SMA/GDA GDA GDA SPA SPA Not identified
23 F Insulinoma SMA/GDA GDA GDA SPA SPA SPA
60 M Insulinoma SMA GDA GDA SMA SPA SMA

CA: celiac artery, SMA: superior mesenteric artery, GDA: gastroduodenal artery, SPA: splenic artery, DPA: dorsal pancreatic artery
Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography 565
Fig. 1. A 65-year-old male suspected to have an insulinoma.
(A) Digital subtraction angiography of the celiac artery shows
that the dorsal pancreatic artery is branched from the splenic
artery (black arrow). (B) CT during arteriography of the sple-
nic artery shows that the tail of the pancreas is enhanced. (C)
CT during arteriography of the gastroduodenal artery shows
thickness of 3 mm and a helical pitch of 1.2–1.5. CT
during arteriography was performed 6 s after the
injection of the non-ionic iodine contrast media
(200 mgI/ml) via the catheter placed in each artery. The
injection rate of CT during arteriography was adjusted
that the superior head and body of the pancreas are
enhanced. (D) CT during arteriography of the superior mes-
enteric artery shows that the uncinate process and inferior
head of the pancreas are enhanced (arrowheads). A part of
the superior head of the pancreas is also enhanced.
to 0.8–2.0 ml/s, to minimize the overflow in CT during
arteriography.
CT images during arteriography were evaluated and
the initial enhanced areas of the pancreas on CT during
arteriography were regarded as the area supplied by the
566 Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography
Fig. 2. A 21-year-old female suspected to have chronic
pancreatitis. (A) Digital subtraction angiography of the celiac
artery shows that the dorsal pancreatic artery is branched
from the common hepatic artery (black arrow). (B) CT during
arteriography of the splenic artery shows that the body and tail
infused artery (Figs. 1–3). We investigated which artery
predominantly supplies which region of the pancreas by
using CT during arteriography. The pancreas was di-
vided into five regions: the uncinate process, inferior
head, superior head, body, and tail (Fig. 4). We defined
these regions as follows: (a) The uncinate process was
of the pancreas is enhanced. (C) CT during arteriography of
the gastroduodenal artery shows that the superior head and
body of the pancreas are enhanced. (D) CT during arteriog-
raphy of the superior mesenteric artery shows that the unci-
nate process and inferior head of the pancreas are enhanced.
defined as the portion of the pancreatic head that hooks
around the posterior to the superior mesenteric vein; (b)
The superior head was defined as the cranial half of the
pancreatic head excluding the uncinate process; (c) The
inferior head was defined as the caudal half of the
pancreatic head excluding the uncinate process; (d) The
Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography 567
Fig. 3. A 66-year-old male with an insulinoma. (A) Digital
subtraction angiography of the superior mesenteric artery
(SMA) shows that the dorsal pancreatic artery is branched
from the SMA (white arrow). (B) CT during arteriography of
the SMA shows that the body of the pancreas is enhanced.
body was defined as the region between the pancreatic
head and pancreatic tail. The right edge of the body was
the left edge of the portal vein, and the lengths of the
body and tail were identical; (e) The tail was defined as
the region next to the body.
(C) CT during arteriography of the SMA shows that the
uncinate process and inferior head of the pancreas are also
enhanced. (d) CT during arteriography of the gastroduodenal
artery shows that the superior head of the pancreas is
enhanced.
Based on the angiographic findings from the CA
and SPA, the vascular anatomies were confirmed. The
relationships between the variation of the vascular
supply and the branching patterns of the DPA on
arteriography were also investigated.
568 Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography
Fig. 4. Definition of the regions of the pancreas. (1) the
uncinate process is a portion of the head of the pancreas that
hooks around posterior to the superior mesenteric vein; (2)
the superior head is a portion of a cranial half of the head of
the pancreas except the uncinate process; (3) the inferior
head is a caudal half of the head of the pancreas except the
uncinate process; (4) the body is a portion between the head
and tail of the pancreas. The right edge of the body is the left
edge of the portal vein. The lengths of the body and tail are
same; (5) the tail is a portion next to the body. PV: portal vein.
Results
The uncinate process of the pancreas was enhanced in
CT during arteriography of the SMA in 13 patients
(100%), of the GDA in two patients (15.4%), and of the
SPA in no patients (0%). The inferior head of the
pancreas was enhanced in CT during arteriography of
the SMA in five patients (38.5%), of the GDA in nine
patients (69.2%), and of the SPA in no patients (0%). The
superior head of the pancreas was enhanced in CT dur-
ing arteriography of the SMA in no patients (0%), of the
GDA in 13 patients (100%), and of the SPA in one
patient (7.7%). The body of the pancreas was enhanced
in CT during arteriography of the SMA in seven patients
(46.2%), of the GDA in two patients (15.4%), and of the
SPA in 10 patients (76.9%). The tail of the pancreas was
enhanced in CT during arteriography of the SPA in all 13
patients (100%), but was not enhanced in CT during
arteriography of the GDA and SMA.
The DPA was depicted in 12 patients on arteriogra-
phy. Out of the 12 patients, the DPA branched from the
SMA in four patients (33.3%), from the CA in one
patient (8.3%), from the CHA in one patient (8.3%), and
from the SPA in six patients (50.0%). In all four patients
in whom the DPA branched from the SMA, the body of
the pancreas was enhanced in CT during arteriography
of the SMA (100%). In five of six patients in whom the
DPA branched from the SPA, the body of the pancreas
was enhanced in CT during arteriography of the SPA
(83.3%). In nine of 12 patients, the body was enhanced in
CT during arteriography of the arteries which branch the
DPA (75%).
Discussion
In this study, we found that the SMA predominantly
supplied the uncinate process, the SPA the tail, and the
GDA the superior head of the pancreas in all patients.
We suggest that CT during arteriography is not required
to confirm the supplying artery in these regions.
The blood supply to the inferior head and especially
to the body of the pancreas varied from patient to
patient. When either of these regions of the pancreas is
the clinical focus, it is crucial to determine its precise
blood distribution. To accurately clarify the blood
distribution of these regions, CT during arteriography
might be necessary.
The DPA, however, seemed to mainly supply the
body of the pancreas. The variation of the blood supply
to the body of the pancreas is largely dependent on the
variation of the origin of the DPA (the rate of agreement
was 75% in our study). If we know which artery the DPA
originates from, CT during arteriography may not
always be needed.
Arterial infusion chemotherapy for advanced and
inoperable pancreatic cancer can increase the local con-
centration of anticancer agents. Unfortunately, most
studies had not shown evidence of a survival benefit
compared to systemic chemotherapy [9–14]. Tanaka et
al. suggested that the poor clinical response might have
been due to the inadequate positioning of the catheter tip
positioned in the aorta or CA. They showed using CT
during arteriography that the SMA side of the pancreas
does not perfuse when the tip of the catheter is posi-
tioned in the CA [17].
Several investigators have examined variations in the
vascular supply of regions of the pancreas during
arterial infusion chemotherapy. Ohigashi et al. used
insertion of one or more catheters into the SPA and/or
GDA and/or right gastroepiploic artery during lapa-
rotomy [16]. They injected a blue dye into the catheter
in each patient to determine how the pancreatic tumor
was stained. Homma et al. treated advanced pancreatic
carcinomas by arterial infusion chemotherapy after
isolation of arterial blood flow to the pancreatic tumors
by super-selective embolization of other arteries with
microcoils by selective catheter insertion [15]. They
achieved a 2-year survival rate of 42.8% and 3-year
survival rate of 18.3% for 31 patients with advanced
pancreatic carcinoma. For super-selective embolization
of the pancreatic artery, we must accurately determine
the blood supply to particular regions of the pancreas.
Further improvement of arterial infusion chemotherapy
after hemodynamic change may be achieved by precise
knowledge about the vascular supply to specific regions
of the pancreas after CT during arteriography in each
patient. In particular, we have to pay attention to the
blood distribution of the inferior head and body of
the pancreas, because of the wide range of blood
Yusuke Sakuhara et al.: Evaluation of the vascular supply to regions of the pancreas on CT during arteriography 569
distribution patterns in these areas. In addition, it will
be helpful to know the origin of the DPA for estimation
of the blood distribution of the body.
The findings of this study should also be useful for
non-malignant tumors. For the localization of the insu-
linomas, selective arterial calcium stimulation and hepatic
venous sampling has been shown to be useful in combi-
nation with conventional angiography [1–5]. Doppman
et al. suggested that the GDA supplies the superior head
of the pancreas; the SMA supplies the inferior head and
uncinate process of the pancreas; and the SPA supplies
the body and tail of the pancreas [1]. Our results were
mostly in agreement with theirs, although we did
encounter a few discrepancies. In our study, the inferior
head was often supplied by the GDA, and the body was
often supplied by the branches of the SMA or sometimes
by the GDA. The body was enhanced in CT during
arteriography of the SMA in all four patients in which the
DPA branched from the SMA. This result strongly
indicated that the body of the pancreas is supplied by the
SMA when the DPA branches from the SMA. In inter-
preting the results of this examination, we must take these
facts into consideration. The present study suggests that
the combination of arterial stimulation venous sampling
and CT during arteriography may be the most useful tool
for precisely locating insulinomas.
Anai et al. evaluated the therapeutic effect of arterial
infusion of protease inhibitors and antibiotics for severe
acute pancreatitis using CT during arteriography [8].
They precisely investigated the relationship between the
contrast material distribution and the therapeutic effect
in nine patients. They showed that good drug distribution
to the area of inflammation by proper placement of the
catheter correlated with an improvement of pancreatitis.
The results of our study support their suggestions that the
catheter placement in arterial infusion can influence the
treatment outcome significantly because the vascular
supply to each region of the pancreas is different. Just as
in arterial infusion chemotherapy for cancer, it is crucial
to determine the blood distribution of the inferior head
and body of the pancreas and the origin of the DPA.
There are several limitations in our study. First, the
gravity and viscosity of contrast media are not equal to
those of blood, and therefore, the enhanced area in CT
during arteriography may not always reflect the actual
blood distribution. Second, the existence of a tumor
may change the blood distribution. In this study,
patients with excessive vascular obstructions or severe
stenoses were excluded, but tumor-induced blood cir-
culation changes may have been overlooked. Third,
catheter placement and contrast media injection may
change the blood distribution. Contrast media injection
increases the local blood pressure of the catheter tip,
which may result in a blood distribution change.
Fourth, we analyzed the images of a single detector-row
CT scanner. A multidetector-row CT scanner may
provide detailed and precise information.
In conclusion, there was little variation in the unci-
nate process, superior head or tail of the pancreas in the
present series. However, the blood distribution of the
inferior head and especially the body of the pancreas
varied from patient-to-patient, and the origin of the
DPA seemed to be related to the blood distribution
pattern of the body. We conclude that CT during
arteriography is helpful to provide a detailed and
objective evaluation of the blood distribution, and we
should use this technique whenever the blood distribu-
tion could influence the therapeutic plans or effects,
with a particular focus on the distribution to the infe-
rior head and body.
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