The natural history of celiac artery aneurysms.

OBJECTIVES: The goal of this study was to document the natural history of celiac artery aneurysms (CAAs). BACKGROUND: Celiac artery aneurysms are rare. Existing literature is skewed towards outcomes after intervention of large, symptomatic aneurysms but the behavior of untreated CAAs is poorly understood. METHODS: This is a single institution, retrospective analysis of patients with CAA diagnosed by CT imaging (2015-2019) identified through an institutional radiology database. Radiologic, demographic, and follow-up data were analyzed. The primary endpoint was the mean growth rate of CAAs. RESULTS: Of the 76 patients included, 86.8% were men with a mean age at presentation of 69.8 years. The mean CAA diameter on index imaging was 15.4 +/- 3.8 mm (range, 7-30 mm). All were classified as true aneurysms and 76.3% were saccular. All patients had clinical follow-up with mean follow-up 31.2 months +/- 21.6 months. No patient developed symptoms or rupture. The mean radiological follow-up among 45 patients was 25.2 +/- 16.8 months. Over this period, 16 CAAs (35.6%) enlarged, while 29 (64.4%) remained stable. One patient (1.3%) underwent intervention for increasing size in the setting of a chronic dissection. On multivariate analysis, age <70 was significantly associated with increased risk of aneurysm growth. CONCLUSIONS: In this institutional review of patients with CAAs, the majority of aneurysms remained stable in size, with no patients developing symptoms or rupture over clinical follow-up. Given the observed benign behavior of these aneurysms, guidelines that suggest conservative management of CAAs less than 2 cm seems appropriate.

A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery.

PURPOSE: In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL). METHODS: Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done. RESULTS: Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties. CONCLUSION: This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

Laparoscopic management of median arcuate ligament syndrome: a video vignette.

Median arcuate ligament syndrome (MALS) is a rare condition and a diagnosis of exclusion. We present a 30-year-old man, who had postprandial upper abdominal pain and weight loss of 6 kg in 3 months. His gastroscopy and abdominal ultrasound results were both unremarkable. Computed tomographic angiography showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a 'J' shaped course of artery with poststenotic dilatation and dilated branches of the celiac artery. The patient underwent laparoscopic release of the median arcuate ligament. The intraoperative blood loss was 20 mL and duration of the procedure was 140 minutes. The patient had an uneventful recovery and was discharged on postoperative day 2. The symptoms subsided 2 months following surgery and he started gaining weight. Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method to decompress the celiac artery.

Successful surgical management of a suspected high-flow inferior mesenteric artery aneurysm in a patient with chronic celiac and superior mesenteric artery occlusions.

Inferior mesenteric artery (IMA) aneurysms account for approximately 1% of visceral artery aneurysms and can occur secondary to high flow because of occlusive disease in other mesenteric arteries. We describe the case of a 79-year-old man who presented with a 3.3-cm IMA aneurysm and chronic total occlusions of the celiac artery and superior mesenteric artery (SMA). After an unsuccessful attempt at endovascular SMA recanalization, he underwent an uncomplicated retrograde aorta to SMA bypass and antegrade aorta to IMA bypass. We propose that an aorta to IMA bypass after SMA revascularization is safe and effective to treat suspected high-flow IMA aneurysms.

The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report.

BACKGROUND: Celiac axis stenosis (CAS) is frequently observed in patients undergoing pancreaticoduodenectomy (PD). This poses challenges because of the potential disruption of the hepatic arterial blood flow. CASE PRESENTATION: We present the case of an 81-year-old woman diagnosed with pancreatic head cancer and severe CAS caused by calcification. The patient received neoadjuvant chemotherapy (NAC) and underwent preoperative endovascular stenting of the celiac axis to restore blood flow. After two cycles of NAC, subtotal stomach-preserving PD was performed. An intraoperative assessment of the hepatic arterial blood flow determined that it was well maintained. PD was performed using the standard technique; specialized techniques were not necessary. Importantly, no ischemic complications were encountered. CONCLUSION: This case report describes the successful combination of preoperative celiac axis stenting, NAC, and surgical intervention for the management of CAS in an elderly patient with pancreatic cancer. This approach offers a potential solution for maintaining the hepatic arterial blood flow in the presence of CAS without vascular reconstruction, particularly in elderly individuals.

Intraoperative assessment of blood flow using transabdominal ultrasound during laparoscopic surgery of celiac artery compression syndrome.

Surgical treatment of celiac artery (CA) compression syndrome (CACS) is to release the median arcuate ligament (MAL) by removing the abdominal nerve plexus surrounding CA. In laparoscopic surgery of CACS, objective intraoperative assessment of blood flow in CA is highly desirable. We herein demonstrate a case of laparoscopic surgery of CACS with use of intraoperative transabdominal ultrasound. A 52-year-old woman was presented with epigastric pain and vomiting after eating. Contrast-enhanced computed tomography demonstrated significant stenosis at the origin of CA. Doppler study of CA was also performed, and she was diagnosed as CACS. Laparoscopic surgery was performed, and the MAL was divided. And then, Doppler study using intraoperative transabdominal ultrasound confirmed the successful decompression of CA. This patient was discharged on postoperative day 11, and her symptoms was improved. Intraoperative assessment of blood flow in CA using transabdominal ultrasound was a simple and useful method for laparoscopic surgery of CACS.

Use of selective visceral angiography in surgical strategy planning for celiac artery aneurysm in the celiacomesenteric trunk.

BACKGROUND: The celiacomesenteric trunk (CMT) is a common duct of the celiac artery (CA) and the superior mesenteric artery originating from the aorta, which is an uncommon anatomical variant of visceral artery circulation. Because of the variety of visceral circulation in those with CMT, the visceral circulation associated with each branch should be evaluated prior to surgical treatment of visceral artery aneurysm in the CMT. CASE PRESENTATION: A 64-year-old woman was diagnosed with a CA aneurysm in the CMT. Aneurysmectomy of the aneurysm was performed successfully. On preoperative selective visceral angiography, the CA was seen to bifurcate into the common hepatic and splenic artery. The left gastric artery was directly isolated from the aorta and perfused to the common hepatic and splenic artery through collateral circulation. These findings showed that celiac artery embolization is anatomically feasible, even in cases of celiac artery aneurysm rupture. CONCLUSIONS: Selective visceral angiography can contribute to surgical strategy planning for CA aneurysm with CMT.

[Diagnosis and treatment of Dunbar syndrome]. / Diagnostik und Therapie des Dunbar-Syndroms.

The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.

Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome.

PURPOSE: To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting. CASE REPORT: A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging. CONCLUSION: It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

A gastroduodenal artery that branched from the celiac artery in gastrectomy: A rare case of an anatomical variant.

Understanding anatomical anomalies of the branch of the celiac artery for safe gastrectomy is important. We report a case of laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer with a vascular anatomical anomaly of the celiac artery. A 45-year-old woman was referred to our hospital because of early gastric cancer. Computed tomography showed an anatomical variation of the gastroduodenal artery, which branched from the celiac artery. The celiac artery also branched into the left gastric artery, the splenic artery, and the common hepatic artery. Preoperative understanding of an unusual branch of the celiac artery enabled a safe laparoscopic surgery. There were no postoperative complications. The Adachi classification or Michel classification is used for an anatomical anomaly of the celiac artery, but to the best of our knowledge, this case has not been previously classified and is the first reported case.

Celiac artery occlusion from median arcuate ligament compression complicating a hemorrhagic duodenal ulcer repair.

We present a case of a hemorrhagic duodenal ulcer complicated by occlusion of the celiac artery (CA) by acute median arcuate ligament (MAL) compression. Angiography revealed retrograde flow through the gastroduodenal artery (GDA) to the hepatic artery, with occlusion at the CA origin. This unique presentation required coordinated release of the MAL to reestablish antegrade CA flow before pyloroplasty and GDA ligation. The presence of preexisting MAL compression of the CA should be considered during the repair of bleeding duodenal ulcers through embolization or ligation of the GDA, because impaired CA perfusion could result in foregut ischemia.

A blind-ending branch of celiac artery: a persistent embryologic vascular remnant?

The celiac artery classically divides into three major branches, but it may have variations in branching pattern. Here we report a case of celiac artery having a blind-ending branch in a 54-year-old man who underwent computed tomography of the abdomen before the kidney transplantation surgery. Preprocedural assessment of celiac artery variations is critical for surgical and angiographic procedures involving the upper abdomen.

Bilateral pulmonary sequestrations: Distinct types sharing a common celiac artery origin, presented with pneumonia and associated findings in a pediatric case.

A 14-year-old boy presented with shortness of breath, cough, and mild chest pain, with a history of intermittent milder symptoms. Physical examination and initial tests showed mild iron deficiency anemia, elevated C-reactive protein, and normal vital signs. Chest radiograph revealed abnormalities in the left lower zone, leading to contrast-enhanced chest CT. The CT scan revealed bilateral intrapulmonary sequestrations, both deriving blood supply from a common trunk originating from the celiac artery. The patient's symptoms initially attributed to a pulmonary infection improved with antibiotic therapy. Pulmonary sequestration is a congenital anomaly characterized by aberrant lung tissue lacking connections to bronchial tree or pulmonary arteries. It can lead to recurrent pulmonary infections and postinfectious sequelae. This case presented a unique bilateral sequestration, both originating from the celiac artery. Radiologists should be aware of sequestration types and associated anomalies, even in atypical locations. Blood supply can originate from various arteries, not just the aorta.

Median arcuate ligament syndrome complicated with gallbladder stones: A case report.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament (MAL). It can cause symptoms of postprandial abdominal pain, weight loss, and nausea and vomiting. CASE SUMMARY: A 55-year-old woman was admitted due to abdominal pain, nausea and vomiting. On admission, the patient presented with epigastric pain that worsened after eating, without signs of peritoneal irritation. Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk, local luminal stenosis with angular "fishhook" changes, which changed significantly during forceful inspiration and expiration; gallbladder stones; and multiple cysts in the liver. Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s. After diagnosis of MALS was confirmed, an arch ligament release procedure was performed. MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases. Awareness of MALS should be improved to avoid misdiagnosis. The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery. CONCLUSION: The diagnosis and treatment of MALS must be individualized, and MAL release is effective and provides immediate symptomatic relief.

Celiac Artery Aneurysm: A Rare Cause of Abdominal Pain.

We present the case of a 48-year-old male who presented to the emergency department with left-sided abdominal pain of four-day duration. The pain was described as sharp in nature and was located in the left lower quadrant with radiation to the left shoulder. A computerized tomography (CT) scan of the abdomen and pelvis without contrast showed celiac artery enlargement with adjacent inflammatory stranding. There were other chronic findings secondary to prior surgery. A CT angiogram of the abdomen and pelvis was performed, which showed a 10 x 5 mm saccular pseudoaneurysm at the posterior aspect of the celiac trunk with surrounding inflammatory changes. Endovascular repair was accomplished in the operating room after the placement of the stent graft. Repeat angiogram showed successful exclusion of the aneurysm, with excellent perfusion to the arteries distal to the site of repair. The patient was successfully discharged two days later with outpatient follow-up. Celiac artery aneurysms can present to the emergency department with abdominal pain. The detection of celiac artery aneurysms may be increasing due to increased detection on CT scans. Although rare, this type of visceral artery aneurysm carries a high mortality rate if ruptured. Surgical repair may be either through an endovascular approach or through open surgical repair of the aneurysm preferably with prosthetic grafts.

Median Arcuate Ligament and Origin of the Celiac Artery Proximity Change in Patients after Surgery to Correct Adult Spinal Deformity: Potential Risk Factors for Acute Celiac Artery Compression Syndrome.

Introduction: This study aimed to determine whether the proximity of the median arcuate ligament (MAL) and the celiac artery (CA) changes in patients following surgery to correct adult spinal deformity (ASD). We hypothesized that the distance between the MAL and the CA shortens after corrective spinal surgery, which may cause acute celiac artery compression syndrome (ACACS). Methods: A total of 89 patients (68.4±7.6 years; 7 men/82 women) with ASD treated with spinal correction surgery were included in the present retrospective study. The level of the MAL, CA, and distance between the MAL and the CA (DMC) were determined via reconstructed computed tomography. MAL overlap was determined preoperatively and postoperatively. Results: The MAL and CA moved caudally following surgery. On average, after surgery, no changes in DMC were observed. We found preoperative MAL overlap in 32 (36%) patients, who also had postoperative MAL overlap. No patients showed any MAL overlap postoperatively. Conclusions: Contrary to our hypothesis, the distance between the MAL and the CA did not shorten, and emerging MAL overlap was not observed postoperatively.

Open surgical repair of a giant celiac artery aneurysm with complex anatomy using a retrograde balloon occlusion technique.

Several options exist for the treatment of celiac artery (CA) aneurysms (CAAs), including surgical repair and endovascular procedures. However, treatment of CAAs can be challenging owing to their proximity to the ostium of the CA and involvement of the CA branches. In the present report, we have described a case of a giant CAA extending from the proximal CA to the hepatosplenic bifurcation. Owing to the anatomic complexity of this CAA, proximal control was a major therapeutic concern. The patient underwent open aneurysmectomy using the retrograde balloon occlusion technique to control the inflow of the CAA, with a satisfactory result.

Spontaneous Celiac Artery Pseudoaneurysm in a Patient With Viral Myocarditis: Coincidence or Consequence?

Spontaneous pseudoaneurysm formation in the celiac artery is a very infrequent occurrence in the absence of trauma or descending aortic dissection. If it continues to progress, it can lead to visceral organ infarction or life-threatening hemoperitoneum. Management is conservative in select cases; however, most patients require an endovascular or surgical approach. The definitive etiology of spontaneous celiac artery pseudoaneurysm remains unclear. We present an intriguing case of a 67-year-old female who presented to the hospital with sudden chest pain preceded by viral prodromal symptoms. She was discharged as a case of viral myocarditis and was re-admitted the same day with acute abdominal pain. Computed tomography with intravenous contrast showed an enlarging eight-millimeter celiac artery pseudoaneurysm managed with endovascular coil embolization. This case report demonstrates spontaneous celiac artery pseudoaneurysm workup and management. We are also investigating whether a unifying diagnosis exists to explain both viral myocarditis and celiac artery pseudoaneurysm or if both conditions are sporadic occurrences.

Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk.

Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.

Overview of Median Arcuate Ligament Syndrome: A Narrative Review.

Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.