CASE 15429 Published on 09.02.2018

A large symptomatic coeliac artery aneurysm

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

D. Campos Correia, Joao D. Oliveira, I. Amaral, T. Saldanha

Centro Hospitalar de Lisboa Ocidental; Rua da Junqueira, 126 1349-019 Lisboa, Portugal; Email:davidcorreia7@gmail.com
Patient

50 years, male

Categories
Area of Interest Abdomen ; Imaging Technique CT, Ultrasound
Clinical History

A 50-year-old patient presented to the ER department with epigastralgia which had started around 6 hours prior. Serum lipase and creatine kinase were elevated. There was no previous history of pancreatitis.

Imaging Findings

An abdominal ultrasound was initially performed revealing a large, hypoechoic heterogeneous lesion in the epigastric region, with an anechoic area in the centre that showed the classic yin-yang sign on Doppler-US, indicating bidirectional flow (Figure 1).
Contrast-enhanced CT was then performed revealing an area of patent lumen with increased attenuation due to contrast enhancement and a large portion of the peripheral lumen showing reduced attenuation due to eccentric mural thrombus (Figure 2a). Posteriorly, a compressed but otherwise normal-appearing pancreas, with no significant peripancreatic abnormalities, could be seen (Figure 2d). There was very mild densification of the peri-aneurysmal fat, but no signs of acute haemorrhage were present.
The combination of 2D enhanced-CT images (Figure 2) and 3D reformations (Figure 3) made it possible to localise the large (8cm) aneurysm to the hepatic-splenic bifurcation of the coeliac trunk.

Discussion

Coeliac artery aneurysms are extremely rare and represent approximately 4% of all splanchnic artery aneurysms [1]. Like all other splanchnic artery aneurysms, they are defined as a localised dilation of the mesenteric vasculature greater than 1.5 times the normal diameter of an artery involving all 3 layers of the vessel wall [1].
Common causes include arteriosclerosis and medial degeneration, other less common causes being trauma, dissection and Takayasu arteritis [1].

Symptomatic coeliac trunk aneurysms usually manifest initially by epigastric pain or upper gastrointestinal haemorrhage. Recent series have reported a lifetime risk of rupture of approximately 6% [2]. Calcification, aneurysm size and thrombus formation are not considered risk factors for rupture [2].

Four approaches have been described regarding splanchnic aneurysm management: no management, close observation, percutaneous intervention and open surgical repair [3]. Unlike a few other types of splanchnic artery aneurysms, which can be repaired by endovascular methods, most coeliac artery aneurysms require open repair [4].

Current guidelines for coeliac artery aneurysm repair suggest considering repair of lesions >25 mm in surgical candidates [4]. Lesions measuring 25mm or less should be monitored with contrast-enhanced CT every 3 years [4].

In our patient, due to physical examination and serum lipase levels, the diagnosis of mild acute pancreatitis was considered. Nevertheless, CT showed a compressed but otherwise normal-appearing pancreas with no significant peri-pancreatic abnormalities. Some authors have described the rare occurrence of recurrent episodes of acute pancreatitis due to aneurysmal compression [5].
Due to its size, the patient was immediately submitted to open surgical repair of the coeliac aneurysm. No significant complications ensued.

Differential Diagnosis List
Coeliac artery aneurysm
Common hepatic artery aneurysm
Superior mesenteric artery aneurysm
Final Diagnosis
Coeliac artery aneurysm
Case information
URL: https://www.eurorad.org/case/15429
DOI: 10.1594/EURORAD/CASE.15429
ISSN: 1563-4086
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