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Surg Radiol Anat
DOI 10.1007/s00276-014-1276-8
Original Article
The superior horizontal pancreatic artery of Popova: a review
and an anatomoradiological study of an important morphological
variant of the pancreatica magna artery
S. Mosca · F. Di Gregorio · M. Regoli · E. Bertelli
Received: 10 December 2013 / Accepted: 17 February 2014
© Springer-Verlag France 2014
Abstract
Purpose The superior horizontal pancreatic artery was
described in 1910, and after a few years, it was forgot by
most investigators. This research is aimed to revive the
description of this artery, describing course, pattern of
branching and frequency.
Methods More than 1,000 of angiographies including
studies of the superior mesenteric artery, celiac trunk and
its branches, were selected from the angiographic archives
of the ex-institutes of Radiology of Siena, Rome (University of Sacro Cuore) and Perugia, and the arterial anatomy
of the pancreas was studied.
Results A pancreatic branch of the splenic artery running
along the superior border of the pancreatic body and tail
was observed in 25.93 % of cases. This branch matched the
description of the superior horizontal pancreatic artery and,
when existing, replaced the pancreatica magna artery. For
this reason, we considered the superior horizontal pancreatic artery as a variant of the pancreatica magna artery. Variable in caliber and importance, in most cases the superior
horizontal pancreatic artery gave off descending branches
that anastomosed with the inferior pancreatic artery.
Conclusions A superior horizontal pancreatic artery could
be visualized more easily by selective angiography of the
S. Mosca
Department of Diagnostic Imaging, University of Perugia,
Perugia, Italy
F. Di Gregorio
Department of Bioimaging and Radiological Sciences,
Catholic University of Sacro Cuore, Rome, Italy
M. Regoli · E. Bertelli (*)
Department of Life Sciences, University of Siena,
Via Aldo Moro 2, 53100 Siena, Italy
e-mail: eugenio.bertelli@unisi.it
splenic artery. When coupled with the inferior pancreatic
artery, the presence of the superior horizontal pancreatic
artery outlined a longitudinally arranged pattern of blood
supply of the distal pancreas that should be known. In particular circumstances, extended resections of the gland cutting both longitudinal arteries might jeopardize the surviving of the pancreas remnant.
Keywords Pancreas · Blood supply · Pancreatica magna
artery · Superior horizontal pancreatic artery
Introduction
The pancreatic blood supply has received considerable
attention over the time due to its high variability. In spite
of this, a general agreement on the main arteries supplying the pancreas has been reached even though they show
ample variations in incidence, branching pattern and site
of origin (Fig. 1). The head of the pancreas is supplied
by two anastomotic pancreaticoduodenal arcades joining the superior mesenteric artery with the gastroduodenal artery [3–6]. In addition, the head is also served by the
right branch of the dorsal pancreatic artery that anastomoses with the gastroduodenal artery. The dorsal pancreatic
artery, in turn, is often the largest pancreatic artery [7]. It
arises behind the neck of the pancreas, mostly from the
first tract of the hepatic or splenic artery, the celiac trunk
or the superior mesenteric artery [7]. The dorsal pancreatic
artery gives rise to several minor branches [7, 32] and usually ends close to the inferior edge of the pancreatic neck
dividing into two arteries running in opposite directions:
the above-mentioned right branch that, forming the prepancreatic arcade and joining the gastroduodenal artery, supplies the head of the pancreas, and a left branch that runs
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Surg Radiol Anat
Fig. 1 a Schematic drawing of the pancreatic blood supply as generally showed in most textbooks and articles. Two pancreaticoduodenal
arcades, anterior (APDA) and posterior (PPDA), join the gastroduodenal artery (GD) and the superior mesenteric artery (SM) and supply
the head of the pancreas. The dorsal pancreatic artery (DP) descends
behind the neck of the gland and divides into two opposite branches:
a right one, forming the prepancreatic arcade (PPA) and joining the
gastroduodenal artery, and a left one that courses toward the tail of
the gland as the inferior pancreatic artery (IP). Two additional arteries are usually shown: the pancreatica magna artery (PM), stemming
from the splenic artery (S), penetrates into the body of the pancreas
and joins the inferior pancreatic artery, and the caudal pancreatic
artery (CP), arising from the last portion of the splenic artery and
likewise ending into the inferior pancreatic artery; b schematic drawing of the pancreatic blood supply when a superior horizontal (SH)
artery is present. The only difference with a is that the regular pancreatica magna artery is replaced by its transverse variant, the superior
horizontal artery. This artery runs nearby the superior margin of the
pancreas and gives off several descending branches that usually join
the inferior pancreatic artery (IP)
toward the tail of the gland along its inferior border. This
branch is usually referred to as transverse or inferior pancreatic artery [7]. The body of the pancreas is also supplied
by the pancreatica magna artery, which reinforces the inferior pancreatic artery; the tail, in addition of being served
by branches of the pancreatica magna artery, also receives
few caudal arteries. The pancreatica magna artery and most
of the caudal pancreatic arteries originate from the splenic
artery. The pancreatica magna artery, also known merely
as large pancreatic artery [20] or arteria corporis pancreatis [34], is said to enter the pancreas at the junction of the
middle and distal thirds of the gland [35]. Observed with
an incidence ranging between 64 and 98 % of cases [8, 31,
34, 35], it descends behind the pancreatic duct and joins
the inferior pancreatic artery [20, 22] in about 80 % of
cases [31]. In spite of the description carried out by Vandamme [33, 34], the pancreatica magna artery is commonly
believed, and accordingly showed, to behave very alike the
dorsal pancreatic artery giving off two opposite terminal
branches (Fig. 1a) and contributing in this way to extend
the course of the inferior pancreatic artery [1, 8, 11, 20, 21,
23, 27, 28, 30, 35].
The inferior pancreatic artery can exist even though the
dorsal pancreatic artery does not [24]. In this case, it arises
from the gastroduodenal artery, the right gastroepiploic
artery or the anterior superior pancreaticoduodenal artery,
and crossing anteriorly the pancreatic head, it extends toward
the tail of the pancreas as it does when it is a mere branch
of the dorsal pancreatic artery. The inferior pancreatic artery
comes therefore in at least two variants: a short-type, arising from the dorsal pancreatic artery, and a long-type that,
stemming nearby the terminal division of the gastroduodenal
artery, runs along the entire length of the gland [2]. This distinction is relevant as the long-type inferior pancreatic artery
supplies the head of the pancreas in addition to the body
and tail which, in contrast, are the only portions served by
the short-type. A careful analysis of a long series of angiographies allowed us to observe with a certain frequency the
existence of a vessel arising from the splenic artery that,
with a transverse course, often doubled the inferior pancreatic artery (Fig. 1b). When existing, this vessel replaced
the pancreatica magna artery, and for this reason, we have
considered it as an important morphological variant of the
latter artery. In spite of its horizontal course, it differs from
the inferior pancreatic artery for its origin, directly from the
splenic artery, and for the course located along the superior border of the body and tail of the pancreas. This course
closely matches the previously reported superior horizontal
pancreatic artery of Popova [25], a vessel that, after a brief
appearance in the literature, shortly fell into oblivion. As we
believe that the superior horizontal pancreatic artery of Popova may bear clinical importance, we decided to carry out
an anatomic study on its general morphology, incidence and
course using angiographic archive material; as we consider
the superior horizontal pancreatic artery of Popova as a morphological variant of the pancreatica magna artery, we also
reviewed briefly the latter artery.
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Materials and methods
For a detailed description of the materials and methods of
this research, we refer to a previous publication in this journal [3]. At any rate, we briefly summarize the points of main
Surg Radiol Anat
Fig. 2 a Selective angiography of the splenic artery; b selective angiography of the celiac trunk; c schematic drawing summarizing the
relevant arteries visualized with the angiographic study. A very thin
superior horizontal pancreatic artery (SH) supplies the body of the
pancreas running leftward close to the superior border of the pancreas
and anastomosing with one caudal artery (CP). A dorsal pancreatic
artery (DP) is visible issuing from the celiac trunk. The system of
the caudal and superior horizontal pancreatic arteries is anastomosed
with the inferior pancreatic artery (IP) that marks the inferior border
of the pancreas. S splenic artery, CH common hepatic artery, C celiac
trunk
interest: The present investigation was carried out consulting the angiographic archives of the ex-institutes of Radiology of Siena, Rome (Catholic University) and Perugia. The
radiologic examinations of the above-mentioned archives,
performed between the years 1983 and 1991, were aimed at
studying splenic, intestinal, pancreatic and hepatic pathologies. After having discarded all the examinations which
were not suitable for interpreting the vascular anatomy, only
1,015 angiographies were taken into consideration for the
anatomic study and included 507 selective angiographies of
the superior mesenteric artery, 316 of the celiac trunk, 125
of the common hepatic artery and 67 of the splenic artery.
Though the iconography of this investigation has been compiled using the entire collection of angiographies, data on
the incidence of the superior horizontal pancreatic artery
and of its main features were drawn exclusively from the
series of selective angiographies of the splenic artery.
The superior horizontal pancreatic artery did not represent as exception to the general variability of the pancreatic blood supply. Actually, it showed a variable degree of
development and importance, its diameter ranging from
that of a very thin artery (Fig. 2) to about one-third of the
splenic artery caliber (Fig. 3). The superior horizontal pancreatic artery always originated directly from the splenic
artery (Fig. 3), but in rare instances (3 % of cases) a vessel
that could be mistaken for the superior horizontal pancreatic artery appeared as an early branch of the dorsal pancreatic artery (Fig. 4). This vessel was more an anastomotic
channel joining the pancreatic branches descending from
the splenic artery (the dorsal pancreatic artery with the pancreatica magna artery and the pancreatic magna artery with
the caudal pancreatic artery) than an independent artery.
With the superior horizontal pancreatic artery, this vessel
shared the longitudinal course close to the superior border
of the pancreas. However, as in these cases a regular pancreatica magna artery could be identified (Fig. 4), we did
consider it merely as a second transverse pancreatic artery.
The superior horizontal pancreatic artery supplied variable portions of the distal pancreas. It could appear restricted
to the tail of the pancreas (Fig. 5), or it could even extend
its territory of competence to part of the body (Fig. 6). In
most instances (70.6 % of cases), particularly when it was
well developed, the superior horizontal pancreatic artery
was co-existing with the inferior pancreatic artery, with
which it was often joined through several fine descending branches (Figs. 2, 3, 4, 5), and sometimes (17.6 % of
cases), it could end anastomosing with the caudal pancreatic artery (Fig. 2). Less frequently (11.7 % of cases), the
Results
The superior horizontal pancreatic artery of Popova could
be identified in angiographic studies of the celiac artery,
especially when combined with those of the superior mesenteric artery. However, due to the overlapping of vessels of
the gastric and colic areas, in several cases the identification
of this artery was doubtful. Therefore, in order to achieve
an estimation of its incidence, we relied only on the selective angiographies of the splenic artery that were much less
numerous. In such conditions, a superior horizontal pancreatic artery could be identified in 25.93 % of cases.
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Surg Radiol Anat
Fig. 3 a Selective angiography of the splenic artery; b schematic
drawing summarizing the relevant arteries visualized with the angiographic study. The splenic artery (S) gives rise to a superior horizontal artery (SH) that runs leftward giving rise only to fine descending
branches (DB), some of them anastomosing with the inferior pancreatic artery (IP) that appears filled with the contrast medium. After
giving off the superior horizontal pancreatic artery, the splenic artery
does not give rise to any other visible pancreatic branch. The superior
horizontal pancreatic artery possibly continues as an epiploic artery
(arrowheads, EA) that shows a sinuous course at first ascending and
then descending
Fig. 4 a Selective angiography of the splenic artery; b schematic
drawing summarizing the relevant arteries visualized with the angiographic study. The splenic artery (S) gives rise to four visible pancreatic branches, three of them corresponding to the dorsal pancreatic artery (DP), the pancreatica magna artery (PM) and the caudal
pancreatic artery (CP). The fourth branch (1) is small but it helps to
visualize the pancreatic silhouette. A fifth branch stems from the inferior splenic branch at the hilus of the spleen (2). The dorsal pancreatic
artery descends rightward, and at the inferior margin of the gland, it
divides into the usual right and left branches respectively prepancreatic arcade (PPA) and inferior pancreatic artery (IP). From the proximal part of the dorsal pancreatic artery stems, a branch (3) that runs
leftward to join the pancreatica magna artery which, in turn, gives
rise to a similar branch (4) that joins the caudal pancreatic artery.
A second transverse pancreatic artery is formed by the continuity
among vessel 3, the pancreatica magna artery, vessel 4 and the caudal
pancreatic artery
artery appeared as the only artery supplying the distal pancreas with descending branches that did not meet visible
inferior pancreatic arteries (Fig. 6).
In almost all cases (88.23 % of cases), the superior horizontal pancreatic artery divided in a comb-like fashion giving off several descending branches; they distributed to the
pancreas and/or ended anastomosing with the inferior pancreatic artery (Figs. 3, 4, 5).
Discussion
13
In our series of angiographies, the superior horizontal
pancreatic artery appears in about one case out of four.
A selective angiography of the splenic artery is probably
the best condition to identify the superior horizontal pancreatic artery due to the lack of overlapping vessels of the
gastric or colic areas that appear after injecting the celiac
Surg Radiol Anat
Fig. 5 a Angiography of the celiac trunk; b angiography of the superior mesenteric artery; c schematic drawing summarizing the relevant
arteries visualized with the angiographic study. The celiac artery is
affected by a stenosis that determines the enlargement of all the anastomotic pathways joining the mesenteric and the celiac arterial districts, including the pancreaticoduodenal arcades, the prepancreatic
arcade, the inferior pancreatic artery and the pancreatic branches of
the splenic artery. The combined angiographic approaches allow the
identification of the superior horizontal pancreatic artery (SH). The
angiography of the celiac trunk shows a large pancreatic branch (SH)
issuing from the splenic artery (S) with a leftward course. The vessel runs along the superior margin of the pancreas as demonstrated
by the angiography of the superior mesenteric artery showing an inferior pancreatic artery (IP) that marks the inferior border of the gland.
In this case, the dorsal pancreatic artery is injected with contrast
medium via the superior mesenteric artery. An additional pancreatic
branch (1) of the splenic artery, visible only in b, is injected through
the inferior pancreatic artery. Also, the left gastroepiploic artery
(LGE) is visible only in b, and it is injected through the superior horizontal pancreatic artery and/or the inferior pancreatic artery
Fig. 6 a Selective angiography of the splenic artery; b schematic
drawing summarizing the relevant arteries visualized with the angiographic study. A very large superior horizontal pancreatic artery (SH)
stems from the second third of the splenic artery (S) and supplies the
tail and the distal half of the body of the pancreas. The silhouette of
the gland is clearly outlined, and though any inferior pancreatic artery
is visible, the superior horizontal pancreatic artery can be easily
assigned to the superior margin of the pancreas
or superior mesenteric arteries. Still, even with a selective
angiography, the splenic artery itself can partially eclipse
the superior horizontal pancreatic artery sometime hindering the certain identification of the vessel. In other cases,
in absence of other radiologic reference points, a superior
horizontal pancreatic artery can be mistaken for an inferior pancreatic artery. For instance, it is easier to identify
a superior horizontal pancreatic artery when its course
is paralleling a regular inferior pancreatic artery, which
is known to follow the inferior border of the pancreas.
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Surg Radiol Anat
Fig. 7 a Selective angiography of the splenic artery; b
schematic drawing summarizing
the relevant arteries visualized
with the angiographic study.
A pancreatica magna artery
(PM) is visible descending from
the middle third of the splenic
artery (S) and joining the inferior pancreatic artery (IP) at the
inferior margin of the pancreas.
The course and branching pattern of the pancreatica magna
artery are similar to the dorsal
pancreatic artery (DP), only
placed more distally at the level
of the body of the pancreas.
Barium (B) remnants from a
previous examination are visible
in the descending colon
By angiography, in absence of a precise reference for the
pancreatic margins, it is difficult to assign the course of a
transverse vessel to the inferior or the superior border of
the gland, particularly when the pancreatic region appears
distorted by pathologic processes. It is therefore our feeling
that the true anatomic incidence is likely higher than the
25.93 % we estimated, possibly close enough to Evrard’s
evaluation [14], which was a little higher than one-third of
cases. Clearly, additional studies using computed tomography angiography should help to ascertain a more reliable value, closer to the true anatomic incidence. However,
when the superior horizontal pancreatic artery is thin, even
computed tomography angiography could fail to spot it.
In light of its relatively high incidence, it is puzzling
how this vessel has been forgotten after few years from its
original description [25] being recalled only by few investigators [14, 17, 29]. This is probably due to the fact that,
when existing, the superior horizontal pancreatic artery
mostly seems to replace the pancreatica magna artery. It
is therefore likely that it has skipped the attention of most
researchers as it was considered just as a pancreatica magna
artery. It is interesting to note that up to 1930s, the pancreatica magna artery, as we know it today, still seemed to
be unknown by most investigators [12, 14, 17, 24, 26], and
this very same name was often reserved to the artery that
we now refer to as dorsal pancreatic artery [12, 14, 29]. To
our knowledge, it is only after Michels’ article on the variations of the splenic artery [20] that the term large pancreatic
artery (pancreatica magna artery) became more commonly
used to identify a vessel with roughly the same site of origin of the superior horizontal pancreatic artery which, as
we said, fell into oblivion. The nomenclature of the pancreatic arteries is a long-lasting point of confusion particularly
in what concerns the name pancreatica magna artery [7]
that has been used for a long time (up to 1970s) either as
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a synonym for the dorsal pancreatic artery [9, 10, 13] or as
we intend it today to indicate an artery arising from second
portion of the splenic artery [1, 20–23, 27, 35]. Indeed, just
because the anatomy of the pancreatic arteries is complex
and confusing, we do not think that a novel artery should
be added to the general scheme that is currently accepted
(Fig. 1a). Nevertheless, we believe that within the perimeter
of the pancreatica magna artery, a distinction between an
artery showing a regular descending course and an artery
with the features of the superior horizontal pancreatic
artery should be kept in mind. Indeed, when comparing the
behavioral and branching pattern of a regular pancreatica
magna artery (Fig. 7) with that of a well-developed superior horizontal pancreatic artery (Fig. 3), the differences
appear striking and justify reviving an old name. That the
pancreatica magna artery can show a various morphology,
however, is not so surprising as it may be inferred by the
description that Vandamme et al. [33] made of this artery.
They affirmed that the pancreatica magna artery lies on
the superior border of the pancreas and that it branches in
a comb-like fashion giving off small descending rami that
enters the substance of the gland contributing to the formation of the inferior pancreatic artery: a description more
fitting to the superior horizontal pancreatic artery than to
the commonly acknowledged pancreatica magna artery.
Actually, a pancreatic magna artery with the features of a
superior horizontal pancreatic artery can be easily observed
in anatomic specimens injected with contrast medium by
several authors [1, 21, 34]. Though not sufficiently underlined, the variable morphology of the pancreatica magna
artery has been admitted by other authors that observed a
vertical course in 96 % of cases versus a transverse one in
4 % of cases [31]; however, if we assume the artery with a
transverse course having the features of a superior horizontal pancreatic artery, the incidence reported by Toni et al.
Surg Radiol Anat
[31] appears much lower than ours or the one observed by
Evrard [14]. The difference in the statistical surveys can be
expected as Toni et al.’s analysis of the pancreatic arteries
was carried out using exclusively standard angiographies of
the celiac artery [31] that, as discussed earlier, can be more
troublesome for the identification of the superior horizontal
pancreatic artery.
The presence of the superior horizontal pancreatic artery
coupled with the inferior pancreatic artery (the most frequent occurrence) outlines a previously acknowledged
longitudinally arranged arterial blood supply pattern of
the body and tail of the pancreas [16, 18, 19]. According
to Mellière [19], an arterial arrangement like this, where
the distal part of the pancreas is served only by transverse
arteries that do not anastomose with the splenic artery,
occurs in ¼ of cases, which is roughly the same incidence
that we determined for the superior horizontal pancreatic
artery. When such an arterial pattern exists, an extended
pancreatic resection leaving the distal part of the body and
tail of the pancreas is virtually impossible.
Conflict of interest The authors declare that they have no conflict
of interest.
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