CASE 2241 Published on 15.09.2003

Association of an asymptomatic visceral aneurysm with stenoses of the coeliac trunk

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Böttcher J, Malich A, Rott A, Petrovitch A, Kaiser WA

Patient

74 years, male

Categories
No Area of Interest ; Imaging Technique CT, CT
Clinical History
Smoker with unstable angina pectoris and hypertension. Abdominal ultrasound revealed an infrarenal aneurysm of the abdominal aorta.
Imaging Findings
The patient, a smoker with progressive unstable angina pectoris, was admitted to the Department of Cardiovascular Surgery for preoperative diagnosis. On admission the patient was dyspnoeic and hypertensive. There were no abdominal complaints. Preoperative abdominal ultrasound discovered an infrarenal aneurysm of the abdominal aorta. For clarification of the findings, computed tomography (CT) and digital subtraction angiography (DSA) were carried out.

Spiral CT, including CT angiography of the visceral arteries and abdominal aorta, was performed before and after intravenous application of 120ml Optiray 300 (Mallinckrodt, USA) with 3.5ml/sec flow rate and 30sec delay and an acquisition of 5/8/5.

The CT scans demonstrated significant arteriosclerosis of the abdominal aorta, involving the superior mesenteric artery and the coeliac trunk and their branches. Furthermore, the CT scans confirmed the ultrasound findings of hepatomegaly, nephrolithiasis on the right side and bilaterally located renal cysts.

After bolus application of contrast medium, the CT scans revealed an infrarenal aneurysm of the aorta abdominalis, with an extent of 40mm x 48mm and a length of about 68mm, and a partially intramurally located thrombosis. In addition the scans revealed a dilatation of the pancreaticoduodenal arcades and an aneurysm of the pancreaticoduodenal artery without any signs of thrombosis or rupture.

A combination of 2D- and 3D-reconstruction of the CT scans after application of contrast agent verified a plaque-associated stenosis of the coeliac trunk and in addition a high-grade stenosis at the origin of the common hepatic artery (Figs 1 and 2).

Digital subtraction angiography (DSA) of the visceral arteries and abdominal aorta verified a high-grade stenosis of the coeliac trunk involving especially the origin of the hepatic artery. This may have resulted in the development of a collateral blood circulation with caudocranial flow through extended pancreaticoduodenal arcades and retarded filling of the hepatic artery. Furthermore, DSA verified an aneurysm of the pancreaticoduodenal arcades, with an extent of 21mm x 18mm and a length of about 20mm, without any signs of rupture or thrombosis (Fig. 3). The infrarenal aneurysm of the abdominal aorta was confirmed as well.

The contrast-enhanced CT scans with 2D/3D-reconstruction revealed a high-grade stenosis of the coeliac trunk involving the origin of the common hepatic artery and a further plaque-associated stenosis involving the origin of the coeliac trunk. These findings were in accordance with the results of the digital subtraction angiography, which additionally demonstrated significant haemodynamic changes with viscero-visceral arterial collateral circulation via extended pancreaticoduodenal arcades with a caudocranial flow direction. Angiography showed also retarded filling of the hepatic artery via the extended pancreaticoduodenal arcades. We postulate that the occurrence of the aneurysm of the pancreaticoduodenal arcades was based on the haemodynamic changes associated with the stenoses of the coeliac trunk and the hepatic artery. Without a histopathological examination a fibromuscular dysplasia cannot be excluded. We found no angiographic signs of coeliac trunk compression by the median arcuate ligament and the CT showed no effacement or narrowing of the coeliac axis by a typical anterior soft tissue band.

In the history of the patient and in the clinical examination no signs of former rubella infection or pancreatitis could be found and furthermore the CT showed no morphological alterations of the pancreas.
Discussion
Visceral artery aneurysm is a rare but important form of vascular pathology. In less than 20% of all cases the aneurysm is located at the superior mesenteric artery and the pancreaticoduodenal arcades [1]. In only two cases simultaneous association between stenosis or occlusion of the coeliac trunk and the occurence of an aneurysm of the pancreaticoduodenal arteries was reported [2,3]. Often the visceral aneurysms are found in combination with non-visceral aneurysms, caused by arteriosclerosis or fibromuscular dysplasia. Treatment of visceral artery aneurysms is realised by angioembolisation [4] or surgical revision [5].

Finally we would like to emphasise that CT-angiography and especially 2D/3D-reconstruction of CT scans can be an important diagnostic tool for detection of multiple stenoses or malformations in the visceral arteries.
Differential Diagnosis List
Unruptured asymptomatic visceral aneurysms associated with stenoses of the coeliac trunk
Final Diagnosis
Unruptured asymptomatic visceral aneurysms associated with stenoses of the coeliac trunk
Case information
URL: https://www.eurorad.org/case/2241
DOI: 10.1594/EURORAD/CASE.2241
ISSN: 1563-4086