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Findings: (A) lateral aortograms demonstrates occlusion of the superior mesenteric artery (SMA). (B) AP aortogram demonstrates hypertrophy of the gastroduodenal artery (GDA), superior and inferior pancreaticoduodenal arcade without opacification of the SMA branches. (C) AP aortogram (delayed images) demonstrate opacification of the right colic and ileocolic branches of the SMA, via pancreaticoduodenal branches. Incidentally, there is also atherosclerotic narrowing of the left renal artery and aneurysmal dilatation of the infrarenal aorta.

Diagnosis: SMA occlusion with GDA collateral circulation.

Discussion: When the celiac axis or SMA is occluded, the collateral circulation is achieved via the gastroduodenal artery and the pancreaticoduodenal arcade in the above case. The dorsal pancreatic artery, a branch of the splenic artery, can also provide collateral blood flow to the middle colic artery, a branch of the SMA.

The arc of Barkow offers another collateral pathway via the omental branches of the celiac axis and SMA. The right and left gastroepiploic arteries, branches of the gastroduodenal and splenic artery, give branches to the greater omentum. Tributaries of the transverse pancreatic and the middle colic arteries (branches of the SMA) form the posterior epiploic arteries, which also supply the greater omentum and join the gastroepiploic arteries to form the arc of Barkow.

In rare cases of SMA occlusion, the arc of Buhler, an embryologic remnant of the ventral anastomosis, gives branches to the colon and receives collateral circulation from the inferior mesenteric artery.

References:
Kadir S. Atlas of Normal and Variant Angiographic Anatomy.
W.B. Saunders Co. Philadelphia; 1991:303-306.

Lin PH and Chaikof EL. Embryology, anatomy, and surgical exposure
of the great abdominal vessels. Surg Clin North Am 80(1):417-433, 2000.

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