Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study.

PURPOSE: To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS: Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS: Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION: This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

Nutcracker Phenomenon as a Result of Celiomesenteric Trunk Aneurysm.

A common origin of the celiac trunk and superior mesenteric artery is exceedingly rare, and aneurysms of this common trunk are even rarer. According to our literature search, there are no reported cases of nutcracker syndrome or phenomenon involving this rare aneurysmal anomaly. Repair of such anomalies is standardly via open surgical approach with few reported cases of endovascular repair. We describe a patient with an aneurysm of the celiomesenteric trunk resulting in nutcracker phenomenon of the left renal vein. The celiomesenteric trunk aneurysm was repaired endovascularly, resulting in decreased surrounding inflammation and improvement of the left renal vein compression.

Quadrifurcation Variants of the Celiac Trunk.

BACKGROUND: The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate. METHODS: The CT quadrifurcations were documented on 112 computed tomography angiograms. RESULTS: Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P = 0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA + right hepatic artery+GDA pattern, type 2 had an HGT + right inferior phrenic artery + CHA + SA pattern, type 3 had a gastrophrenic trunk + left inferior phrenic artery+CHA + SA pattern, type 4 showed an left gastric artery + CHA + SA + left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one. CONCLUSIONS: Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report.

PURPOSE: Annular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety. METHODS: Case report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum. RESULTS: Contrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival. CONCLUSION: This was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Congenital superior mesenteric artery aneurysm in a 6-week-old infant presenting with upper gastrointestinal bleeding.

Visceral artery aneurysms are rare in infants and children. The majority of cases are caused by genetic syndromes, trauma, or infection. Although the majority of aneurysms are asymptomatic, visceral artery aneurysms can present with abdominal pain, nausea/vomiting, or rupture. Aneurysm rupture can manifest as hemodynamic instability and/or gastrointestinal bleeding. We present the case of a congenital idiopathic aneurysm of the superior mesenteric artery in a 6-week-old infant who presented with gastrointestinal bleeding. We report a stepwise surgical approach to achieving aneurysm exclusion and thrombosis, and highlight the robust mesenteric collateral circulation that can develop in pediatric patients.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.

The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ©RSNA, 2019.

Endovascular Repair of Anomalous Splenic Artery Aneurysm with Systemic Lupus Erythematosus.

Splenic artery aneurysm with systemic lupus erythematosus is rare but serious. We report a case of a 45-year-old female with systemic lupus erythematosus who presented with a splenic artery aneurysm of anomalous origin from the superior mesenteric artery. This is the first time to report about using an endovascular approach to treat splenic artery aneurysm combined with systemic lupus erythematosus. Endovascular repair of the aneurysm was conducted using a covered stent and multiple coils to exclude both the aneurysm and total splenic artery embolization for treating thrombocytopenia, and this approach was determined to be safe and effective for yielding short-term results.

Arc of Bühler: the surgical significance of a rare anatomical variation.

PURPOSE: The arc of Bühler, an anastomotic vessel between celiac artery and superior mesenteric artery, is a rare anatomic variation. Various radiologic and surgical procedures can be affected by its existence. We aim to review all available information and identify possible clinical implications. METHODS: A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The following terms were utilized in various combinations: "Bühler", "arc of Bühler", "visceral aneurysm", "pancreaticoduodenal arcades". RESULTS: Only 53 cases have been described until today in the literature. The arc of Bühler enhances collateral circulation between celiac artery and superior mesenteric artery alongside with pancreaticoduodenal arcades and dorsal pancreatic artery. Computerized tomography and angiography are the main studies used for its detection and evaluation. Aneurysms of Bühler's arc have been rarely described and seem to share common pathophysiological mechanisms with aneurysms of the pancreaticoduodenal arcades. CONCLUSIONS: Various radiologic and surgical procedures such as embolization or pancreaticoduodenectomy are potentially affected by its existence.

A variant source of arterial supply to the ascending, transverse and descending colon.

Anatomic variations involving arterial supply of the large intestines are of clinical significance. Variations range from the pattern of origin, branching and territorial supply. The colon, the part of the large intestine, usually receives its arterial blood supply from branches of the superior and inferior mesenteric arteries. However, anatomic variation in this vascular arrangement has been reported, with vascular anatomy of the right colon being described as complex and more variable compared with the left colon. During routine cadaveric dissection of the supracolic and infracolic viscera, we encountered an additional mesenteric artery originating directly from the anterior surface of the abdominal aorta between the origins of the superior and inferior mesenteric arteries. This additional "inferior mesenteric artery" ran obliquely superiorly toward the left colon giving rise to two branches supplying the distal part of the ascending colon, the transverse colon and the proximal part of the descending colon. Awareness and knowledge of this anatomic variation are important for radiologists and surgeons to improve the quality of surgery and avoid both intra- and postoperative complications during surgical procedures of the colon.

An accessory right hepatic artery derived from the superior mesenteric artery for anterior right liver lobe supply: a case report.

PURPOSE: During the last decades, it has been established that there are numerous individual anatomical variations of the arterial blood supply in human liver. In the present study, we examined the liver vascularization of an intrahepatic cholangiocarcinoma patient. METHODS: For surgical planning, an enhanced CT scan was performed and a three-dimensional model of liver vascularization constructed. RESULTS: The patient was diagnosed as a Michel's type VII hepatic artery variation. An accessory right hepatic artery arose from the superior mesenteric artery and had distributed into the right anterior liver to provide the blood supply of segments V and VIII, which was more medial than the territory of the right hepatic artery coming from the proper hepatic artery. At the same time, an accessory left hepatic artery originated from the left gastric artery. CONCLUSION: We present a case in which an accessory right hepatic artery provided a territory more medial than a right hepatic artery coming from the proper right artery.

Splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk: a rare anatomical variant.

We report an extremely rare case of splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk variant. This anatomical variation was detected angiographically during hepatic mapping prior to transarterial radioembolization (TARE) for hepatocellular carcinoma in an 84-year-old man. TARE of hepatic tumors is one of the frequent procedures done by interventional radiologists. The identification of such rare vascular aberrations is of great importance not only in current interventional radiology procedures such as radioembolization but also in surgery and diagnostic radiology. To the best of our knowledge, this vascular variant is a novel discovery.

Aneurysm of the Anomalous Splenic Artery Arising from Superior Mesenteric Artery Treated by Coil Embolization: A Report of Two Cases and Literature Review.

BACKGROUND: Aneurysm of splenic artery (SA) which arises from the superior mesenteric artery (SMA) is a very rare condition. The aim of this study was to present our experience with 2 such patients treated by coil embolization. METHODS: A 33-year-old man and a 61-year-old woman were incidentally identified with aneurysms of the SA which arose from the SMA. Endovascular therapy of coil embolization was chosen to treat the aneurysm. RESULTS: Follow-up computed tomography showed no change in the location of the coils and occlusion of majority of the aneurysm sac. The 2 patients have been doing well during a 26-month and 10-month follow-up period, respectively. CONCLUSIONS: Combined with the experience of the previous literature, we think coil embolization can be cost-effective and minimally invasive in selected cases, depending on the morphology and site of the lesion.

Co-existence of the double inferior vena cava with complex interiliac venous communication and aberrant common hepatic artery arising from superior mesenteric artery: a case report.

Variations of the arterial and venous system of the abdomen and pelvis have important clinical significance in hepatobiliary surgery, abdominal laparoscopy, and radiological intervention. A case of double inferior vena cava (IVC) with complex interiliac communication and variation of the common hepatic artery (CHA) arising from superior mesenteric artery (SMA) in a 79-year-old male cadaver is presented. Both IVCs ascended on either side of the abdominal aorta. The left-sided IVC crossed anterior to the aorta at the level of the left renal vein. The union of both IVCs was at the level just above the right renal vein. The diameter of right-sided IVC, left-sided IVC and the common IVC were 16.73 mm, 21.57 mm and 28.75 mm, respectively. In the pelvic cavity, the right common iliac vein was formed by a union of right external and internal iliac veins while the formation of left common iliac vein was from the external iliac vein and two internal iliac veins. An interiliac vein ran from right internal iliac vein to left common iliac vein with an additional communicating vein running from the middle of this interiliac vein to the right common iliac vein. Another co-existence variation in this case was the origin of the CHA arising from the SMA with a suprapancreatic retroportal course. Clinical importance of double IVC are observed in retroperitoneal surgery, whole organ transplantation or radical nephrectomy, surgical ligation of the IVC or the placement of an IVC filter for thromboembolic disease. The variation of CHA has an important clinical significance in liver transplantation, abdominal laparoscopy and radiological abdominal intervention. (Folia Morphol 2018; 77, 1: 151-155).

Abdominal Arterial Anomalies in Children With Alagille Syndrome: Surgical Aspects and Outcomes of Liver Transplantation.

OBJECTIVES: Angiogenic defects secondary to gene mutations of JAG1 and NOTCH2, causing arterial anomalies in Alagille syndrome (AGS), are well described in the literature. The study analyzes the frequency of abdominal arterial anomalies in children with AGS with an emphasis on outcomes following liver transplantation (LT). METHODS: Between 1988 and 2013, 242 children with AGS were treated at our institution. We performed a retrospective analysis of 55 who underwent LT during the study period. Preoperative abdominal arterial findings, operative reports, arterial reconstruction technique, and early as well as late complications following LT were reviewed specifically focusing on arterial thrombosis. RESULTS: Twenty-five patients had preoperative imaging available for analysis. Twelve of these patients showed celiac trunk stenosis (48.0%), 2, a superior mesenteric artery stenosis (8.0%) and one a stenosis of both renal arteries. Twenty patients (36.3%) underwent standard hepatic reconstruction using the native recipient hepatic artery. Thirty-five patients (63.7%) underwent aortic conduit reconstruction (ACR) from the infrarenal aorta using donor arterial conduits. Hepatic artery thrombosis occurred in 9 patients (16.3%). This number was higher in the standard arterial anastomosis group 7/20 (35.0%) than in those with ACR 2/35 (5.7%, P = 0.0079). CONCLUSIONS: In this series, children with AGS pretransplant have a high prevalence of abdominal arterial anomalies. Preoperative abdominal vascular imaging makes it possible to anticipate whether or not a classical arterial revascularization can be performed or whether an ACR is required.

Giant Symptomatic Aneurysm Secondary to Hereditary Hemorrhagic Telangiectasia of a Main Hepatic Artery with Aberrant Origin in Superior Mesenteric Artery.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare disease consistent in vascular dysplasias affecting different organs. Liver involvement includes telangiectases, arteriovenous shunting, and ischemic cholangitis, and its prevalence ranges from 8% to 31%. Spontaneous pseudoaneurysms have never been reported associated to HHT. Several variations in the origin of the main hepatic artery (MHA) have been described in large radiological series and can be found in around 4% of general population. METHODS: A 64-year-old woman with history of HHT was diagnosed of acute symptomatic saccular aneurysm involving the MHA. The associated portovenous fistulae suggested that liver perfusion could be impaired if embolization of the MHA without revascularization was performed. Because of an aberrant origin on the superior mesenteric artery, a hybrid procedure was designed, consistent on endovascular exclusion of the MHA associated with a surgical aortic-hepatic bypass graft. RESULTS: Angio computed tomography (Angio CT) was performed at discharge, 1 month, and 6 months after intervention, revealed complete exclusion of the aneurysm, which reduced 50% in diameter after 6 months. Aneurysms of the MHA can be associated with HHT when intrahepatic arteriovenous fistulae are present. This complication is rare, and the reported cases have been treated by surgical and totally endovascular procedures. The confluence of this very rare condition with an uncommon vascular anatomy makes this a unique case that required the design of a customized intervention. CONCLUSIONS: Hybrid procedures are useful to treat conditions that cannot be solved with standard interventions. Longer series of cases with long-term surveillance are needed to asses the results of these techniques in these complex pathology.

A rare anastomosis between the common hepatic artery and the superior mesenteric artery: a case report.

For decades, anastomoses between unpaired branches of the abdominal aorta have attracted the attention of anatomists, surgeons and radiologists, due to their significance in many clinical procedures. This report presents a rare anastomosis between the common hepatic artery and the superior mesenteric artery, which gave off three branches to the jejunum. The diameter of the anastomosis measured at the point of its branching off the common hepatic artery and at the level of union with the superior mesenteric artery was 4.46 and 4.19 mm, respectively. Moreover, the anastomosis gave off the branch to the head of the pancreas. Both embryological background and potential clinical implications of this variation are discussed. Knowledge of these vascular connections may be important for diagnostic and surgical procedures.

A strange case of superior mesenteric venous collar around the superior mesenteric artery.

During our dissection classes, we saw a venous collar formed around the superior mesenteric artery (SMA) by the jejunal tributaries of superior mesenteric vein in an adult male cadaver. The jejunal tributaries united themselves to form two common jejunal veins. Upper common jejunal vein crossed superficial to SMA and opened into the SMV in front of the uncinate process of pancreas. The inferior common jejunal vein crossed behind the SMA from left to right and opened into the SMV, 4 cm below this level. A communicating vein connected the two common jejunal veins with each other.

The coexistence of both replaced proper hepatic and gastroduodenal arteries due to the common hepatic artery absence.

Anatomical variants of the celiac trunk (CT) branches and especially these of hepatic arteries (HAs) are among the most common variants of the arterial tree. The knowledge of the wide variability in hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic, gastric, and esophageal surgery, as well as in liver transplantations. The purpose of this case report is to describe a rare variant discovered during abdominal dissection of a 74-year-old male cadaver of Greek origin, in which the common hepatic artery was absent and its branches, the proper hepatic artery (PHA) and the gastroduodenal artery (GDA) had an aberrant and separate origin. The entire arterial supply to the liver derived from the aberrant PHA, that originating from the superior mesenteric artery and was named as PHA (RPHA). The RPHA, after a course posterior to the portal vein, terminated into the right and left HAs, at the hilum. The GDA originated from the CT, as well as the left gastric and splenic artery. The right gastric artery originated from the PHA, as usual. The current case emphasizes the necessity of preoperative imaging when evaluating the resectability of a tumor in hepatobiliary and pancreatic area taking into account the possible vascular variations. Abdominal surgeon should be aware of any aberrancy to avoid potential iatrogenic injury and lethal complications.

Variation in morphology and branching pattern of superior mesenteric artery.

The anatomical variations of superior mesenteric artery branches are common. In this study we reported an extraordinary morphology and branching of superior mesenteric artery, during our routine dissection of a 38-year-old Sudanese male cadaver, where the superior mesenteric artery forms an arch over the confluence of inferior vena cava and left renal vein. Other variations observed were: 1) The superior mesenteric artery shares the same origin of coeliac trunk; 2) The unusual origin of right hepatic artery. We think that the knowledge of these variations plays an important role in conducting and planning of radiological and surgical procedures especially in hepatobiliary and pancreatic surgery. Morphology and branching patterns of this artery is anecdotic, which makes this case the most unique.