Association Between Celiac Artery Stenosis With Hepatic Artery Variations and Perioperative Complications in Patients Undergoing Pancreaticoduodenectomy: A Multicenter Retrospective Study

BACKGROUND: Pancreaticoduodenectomy (PD) is a high-risk complex surgery with a high incidence of postoperative ischemic complications, and celiac axis stenosis (CAS) can reduce visceral blood supply and further increase this risk by causing collateral circulation ligation during surgery. Hepatic artery variations (HAV) are common anatomical abnormalities, but the combined impact of CAS and HAV on postoperative complications of PD remains insufficiently studied, and the relevant clinical evidence is scarce. METHODS: From January 2015 to June 2025, we retrospectively analyzed the clinical data of patients who underwent PD at two institutions. Based on preoperative arterial-phase contrast-enhanced computed tomography with sagittal reconstructions, CAS was categorized into four groups: no stenosis (< 30%), Grade A (30%-< 50%), Grade B (50%-≤ 80%), and Grade C (> 80%). HAV were classified according to the Michels classification and further subclassified into three types based on blood supply origin. Both univariate and multivariate logistic regression analyses were conducted to examine the associations between CAS (whether isolated or with concomitant HAV) and perioperative complications. RESULTS: A total of 1187 eligible patients were included, among whom 108 (9.1%) were diagnosed with CAS. Of the CAS cohort, 55 (50.9%) had Grade A stenosis, 36 (33.3%) had Grade B stenosis, and 17 (15.7%) had Grade C stenosis; 82 (75.92%) had extrinsic CAS and 26 (24.07%) had intrinsic CAS. Univariate and multivariate analyses identified that severe CAS (> 80%) and HAV Type III were independent risk factors for bile leakage (CAS > 80%: OR = 6.05, 95% CI = 2.23-16.44, P = 0.023; HAV Type III: OR = 3.12, 95% CI = 1.13-8.62, P = 0.028), postoperative liver dysfunction (CAS > 80%: OR = 4.97, 95% CI = 2.13-11.57, P = 0.017; HAV Type III: OR = 2.53, 95% CI = 1.06-6.05, P = 0.037), and postpancreatectomy hemorrhage (PPH; CAS > 80%: OR = 6.02, 95% CI = 2.38-15.22, P = 0.042; HAV Type III: OR = 3.05, 95% CI = 1.18-7.87, P = 0.043). Increasing CAS severity was associated with higher rates of abdominal infection and Clavien-Dindo ≥ 3 complications. In patients with CAS, Type III HAV was associated with a higher bile leakage and PPH rate, but no significant differences in other complications were observed among HAV subtypes. CONCLUSION: Severe CAS (> 80%) is an independent risk factor for postoperative bile leakage, postoperative liver dysfunction and PPH. HAV Type III further increases the risk of these complications in PD patients with CAS.