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Simple Summary: Distal pancreatectomy with the celiac artery resection (DPCAR) is an oncologically justified procedure for locally advanced pancreatic ductal adenocarcinoma (PDAC). The results of its use in our selective group of 40 consecutive patients demonstrated a high rate of R0-resections, acceptable morbidity, and survival better than that for resectable PDAC. The unsolved problems of this procedure are the liver and stomach ischemic complications, which can be lethal or lead to prolonged hospital stay and deterioration in survival. The existing clinical data do not explain the mechanisms of these specific complications in sufficient detail and can't be used for their prognosis and prevention. We have studied the correlation of clinical data and hemodynamic changes of the collateral arteries in a series of technically homogeneous procedures. The geometrical changes of the pancreatoduodenal arcade elements after DPCAR could explain the causes of ischemic complications after surgery and determine the directions for their prevention. DPCAR's short- and long-term outcomes are highly diverse, while the causes and prevention of ischemic complications are unclear. To assess oncological, surgical, and hemodynamic outcomes of 40 consecutive DPCARs for pancreatic (n37) and gastric tumors (n3) (2009–2021), retrospective analyses of mortality, morbidity, survival, and hemodynamic consequences after DPCAR were undertaken using case history data, IOUS, and pre- and postoperative CT measurements. In postoperative complications (42.5%), the pancreatic fistula was the most frequent event (27%), 90-day mortality was 7.5. With 27 months median follow-up, median overall (OS) and progression-free survival (PFS) for PDAC were 29 and 18 months, respectively; with 1-, 3-, and 5-years, the OS were 90, 60, and 28%, with an R0-resection rate of 92.5%. Liver and gastric ischemia developed in 0 and 5 (12.5%) cases. Comparison of clinical and vascular geometry data revealed fast adaptation of collateral circulation, insignificant changes in proper hepatic artery diameter, and high risk of ischemic gastropathy if the preoperative diameter of pancreaticoduodenal artery was <2 mm. DP CAR can be performed with acceptable morbidity and survival. OS and RFS in this super-selective cohort were compared to those for resectable cancer. The changes in the postoperative arterial geometry could explain the causes of ischemic complications and determine directions for their prevention. [ABSTRACT FROM AUTHOR]