A case of abnormally dilated and tortuous Arc of Buhler and Pancreaticoduodenal arteries in the absence of Celiac Trunk stenosis

Abstract

The Arc of Buhler is a vascular variant describing a persistent remnant of the embryologic ventral anastomosis between the celiac trunk (CT) and superior mesenteric artery (SMA). Prevalence of the Arc of Buhler is estimated to be 3% of the population with only half of those cases being hemodynamically active, invariably reported in the context of CT stenosis. We encountered a case of 1) an abnormally large and tortuous pancreaticoduodenal arcade 2) a large and tortuous Arc of Buhler in the absence of celiac axis stenosis. Absent any evidence of CT stenosis in our donor, this finding represents a previously unreported case of dilated and tortuous anastomotic connections between the celiac axis and the SMA without any obvious causative factors. Due to the abnormal position and tortuous characteristics of this aberrant vessel and the associated prevalence of Arc of Buhler, it is important for clinicians to be aware that this type of anomaly may be present in the general population. The abnormal position may increase risks of herniation and surgical complications, and the tortuous nature may cause increased risk of clot formation. Thus, it is essential that surgeons are aware of such examples of abnormal anatomy both for perioperative considerations and clinical identification of future pathologies. Purpose: To report a case of a persistent, hemodynamically active Arc of Buhler in the absence of CT stenosis. Methods: The variant was discovered during routine cadaver dissection. We acquired transverse biopsies of variant vessels and evaluated their wall thickness. Results: The donor’s anterior PDA, posterior PDA, and Arc of Buhler had larger diameters than literature reported values of a standard human body. Additionally, the posterior PDA had significantly increased wall thickness compared to the other investigated vessels. The common hepatic artery was smaller in diameter than the literature reported ranges. The splenic artery diameter was within the literature reported range. Conclusion: The Arc of Buhler is a remnant of the embryologic ventral anastomosis that is estimated to be present in 3% of the population, but hemodynamically active in only half of those cases. Previous reports have documented hemodynamically active Arcs of Buhler only in cases of CT stenosis. To the best of the authors’ knowledge, this is the first reported case of persistent and hemodynamically active Arc of Buhler in the absence of CT stenosis.