Figure 1
Severe stenosis of celiac trunk
Rupture of pencreaticoduodenal artery aneurysms associated with celiac stenosis due to compression by median arcuate ligament
SectionAbdominal imaging
Case TypeClinical Cases
Authors
Dahila Amal DJEMA
Loan Van LUONG TRINH
Connected authors
67 years, male
Clinical History
67-year-old man treated for HTN. Admitted to the emergency for hypovolaemic shock and severe abdominal pain.
Imaging Findings
CT showing Axial and sagittal reveal severe stenosis of coeliac trunk from extrinsic compression and poststenotic dilation of proximal coeliac artery.
Contrast-enhanced abdominal CT revealed a large mesenteric haematoma, as well as an aneurysmal lesion measuring 15 mm x 15 mm within it. At the late phase, there is a contrast extravasation, in favour of a ruptured aneurysm with active bleeding.
A superior mesenteric arteriogram revealed aneurysmal lesions that developed from the posterior branch of the inferior pancreaticoduodenal artery (PDA). Dilated and tortuous posterior pancreaticoduodenal branches were also demonstrated as numerous collateral arterial networks with retrograde filling of the vascular territory of the coeliac artery.
Superior mesenteric arteriogram demonstrated overt collateral vessels from the vascular territory of the pancreaticoduodenal arcade into the hepatic artery.
Coil embolisation of the corresponding branches of the pancreaticoduodenal artery was performed.
Contrast-enhanced abdominal CT revealed a large mesenteric haematoma, as well as an aneurysmal lesion measuring 15 mm x 15 mm within it. At the late phase, there is a contrast extravasation, in favour of a ruptured aneurysm with active bleeding.
A superior mesenteric arteriogram revealed aneurysmal lesions that developed from the posterior branch of the inferior pancreaticoduodenal artery (PDA). Dilated and tortuous posterior pancreaticoduodenal branches were also demonstrated as numerous collateral arterial networks with retrograde filling of the vascular territory of the coeliac artery.
Superior mesenteric arteriogram demonstrated overt collateral vessels from the vascular territory of the pancreaticoduodenal arcade into the hepatic artery.
Coil embolisation of the corresponding branches of the pancreaticoduodenal artery was performed.
Discussion
Coeliac trunk stenosis or occlusion due to compression by the median arcuate ligament is sporadically seen [1].
With the advances in multidetector row CT, coeliac trunk stenosis or occlusion due to compression by the median arcuate ligament can be clearly demonstrated. Fibrous band-like structures connecting the diaphragmatic crus across the coeliac trunk were seen on contrast-enhanced CT images, which showed possible compression of the coeliac trunk [1].
Angiography was the most useful diagnostic tool in determining the exact location of the aneurysm, the existence or absence of aneurysm rupture, and the haemodynamic changes caused by coeliac trunk stenosis and significantly increased volume of blood flow through the pancreatic arcade from the SMA to the common hepatic artery [2].
Rupture of the aneurysm is the most important event in PDA aneurysms, because it can be life threatening [3].
Rupture was seen in about 45% of all PDA aneurysms associated with coeliac axis stenosis. [3] The management of ruptured PDA aneurysm with coeliac axis stenosis or occlusion varies. The following management strategy is recommended for PDA aneurysm associated with coeliac trunk stenosis due to compression by the median arcuate ligament: transarterial embolisation should be performed in the first instance, and surgical division of the median arcuate ligament should be subsequently performed as early as possible, considering the patient’s condition [4].
Radiologists should be aware of the potential association of coeliac trunk compression by a fibrous band and aneurysm formation in the peripancreatic collaterals. Because of the risk of rupture of the aneurysm, transarterial embolisation should be performed [1].
With the advances in multidetector row CT, coeliac trunk stenosis or occlusion due to compression by the median arcuate ligament can be clearly demonstrated. Fibrous band-like structures connecting the diaphragmatic crus across the coeliac trunk were seen on contrast-enhanced CT images, which showed possible compression of the coeliac trunk [1].
Angiography was the most useful diagnostic tool in determining the exact location of the aneurysm, the existence or absence of aneurysm rupture, and the haemodynamic changes caused by coeliac trunk stenosis and significantly increased volume of blood flow through the pancreatic arcade from the SMA to the common hepatic artery [2].
Rupture of the aneurysm is the most important event in PDA aneurysms, because it can be life threatening [3].
Rupture was seen in about 45% of all PDA aneurysms associated with coeliac axis stenosis. [3] The management of ruptured PDA aneurysm with coeliac axis stenosis or occlusion varies. The following management strategy is recommended for PDA aneurysm associated with coeliac trunk stenosis due to compression by the median arcuate ligament: transarterial embolisation should be performed in the first instance, and surgical division of the median arcuate ligament should be subsequently performed as early as possible, considering the patient’s condition [4].
Radiologists should be aware of the potential association of coeliac trunk compression by a fibrous band and aneurysm formation in the peripancreatic collaterals. Because of the risk of rupture of the aneurysm, transarterial embolisation should be performed [1].
Differential Diagnosis List
Rupture of PDA aneurysms due to compression by arcuate ligament
Spontaneous aneurysm
Haemorragic duodenal ulcer
Final Diagnosis
Rupture of PDA aneurysms due to compression by arcuate ligament
References
[1] Sugiyama K, Takehara Y. (2007) Analysis of five cases of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament. Clin Radiol 62(7):688-93 (PMID: 17556039)
[2] Ikeda O, Tamura Y, Nakasone Y, Kawanaka K, Yamashita Y. (2007) Coil embolization of pancreaticoduodenal artery aneurysms associated with celiac artery stenosis: report of three cases. Cardiovasc Intervent Radiol 30(3):504-7 (PMID: 17242875)
[3] Hongsakul K, Rookkapan S, Sungsiri J, Tubtawee T. (2012) A severe case of median arcuate ligament syndrome with successful angioplasty and stenting. Case Report Vasc Med 10.1155/2012/129870. (PMID: 23050191)
[4] Gümüş H, Gümüş M, Tekbaş G, Önder H, Ekici F, Çetinçakmak MG, Bilici A. (2012) Clinical and multidetector computed tomography findings of patients with median arcuate ligament syndrome. Clin Imaging 36(5):522-5 (PMID: 22920356)
Case information
| URL: | https://www.eurorad.org/case/10808 |
| DOI: | 10.1594/EURORAD/CASE.10808 |
| ISSN: | 1563-4086 |
Figure 3
Interventional Radiology
A superior mesenteric arteriogram revealed aneurysmal lesions from the posterior branch of the inferior PDA. Dilated and tortuous posterior pancreaticoduodenal branches, with retrograde filling of the vascular territory of the coeliac artery.
Superior mesenteric arteriogram demonstrated overt collateral vessels from the vascular territory of the pancreaticoduodenal arcade into the hepatic artery.
Superior mesenteric arteriogram demonstrated active bleeding from the pancreaticoduodenal arcade.
Embolisation of the corresponding branches of the pancreaticoduodenal artery was performed to arrest the bleeding.
Also, coil embolisation of the most largest aneurysm from branch of superior mesenteric artery was performed.
Severe stenosis of celiac trunk
Axial CT showing severe stenosis of coeliac trunk from extrinsic compression and poststenotic dilation of proximal coeliac artery.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.
Sagittal reconstruction CT reveals severe stenosis of coeliac trunk from extrinsic compression and poststenotic dilation of proximal coeliac artery.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
A ruptured aneurysm with active bleeding
Contrast-enhanced abdominal CT revealed a large haematoma.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
as well as an aneurysmal lesion measuring 15 mm x 15 mm within it.
Djema DA, department of radiology, HUG, Geneva, Switzerland.
Djema DA, department of radiology, HUG, Geneva, Switzerland.
At the late phase, there is a contrast extravasation, in favour of a ruptured aneurysm with active bleeding.
Djema DA, Department of Radiology, HUG, Geneva, switzerland.
Djema DA, Department of Radiology, HUG, Geneva, switzerland.
Interventional Radiology
A superior mesenteric arteriogram revealed aneurysmal lesions from the posterior branch of the inferior PDA. Dilated and tortuous posterior pancreaticoduodenal branches, with retrograde filling of the vascular territory of the coeliac artery.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
Djema DA, department of Radiology, HUG, Geneva, Switzerland.
Superior mesenteric arteriogram demonstrated overt collateral vessels from the vascular territory of the pancreaticoduodenal arcade into the hepatic artery.
Djema DA, Department of Radiology, HUG, Geneva, switzerland.
Djema DA, Department of Radiology, HUG, Geneva, switzerland.
Superior mesenteric arteriogram demonstrated active bleeding from the pancreaticoduodenal arcade.
Djema DA, Department of radiology, HUG, Geneva, Switzerland.
Djema DA, Department of radiology, HUG, Geneva, Switzerland.
Embolisation of the corresponding branches of the pancreaticoduodenal artery was performed to arrest the bleeding.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.
Also, coil embolisation of the most largest aneurysm from branch of superior mesenteric artery was performed.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.
Djema DA, Department of Radiology, HUG, Geneva, Switzerland.