Celiac artery stenosis/occlusion treated by interventional radiology

doi:10.1016/j.ejrad.2008.05.005

European Journal of Radiology

Volume 71, Issue 2, August 2009, Pages 369-377

https://doi.org/10.1016/j.ejrad.2008.05.005 Get rights and content

Abstract

Severe stenosis/occlusion of the proximal celiac trunk due to median arcuate ligament compression (MALC), arteriosclerosis, pancreatitis, tumor invasion, and celiac axis agenesis has been reported. However, clinically significant ischemic bowel disease attributable to celiac axis stenosis/occlusion appears to be rare because the superior mesenteric artery (SMA) provides for rich collateral circulation. In patients with celiac axis stenosis/occlusion, the most important and frequently encountered collateral vessels from the SMA are the pancreaticoduodenal arcades. Patients with celiac artery stenosis/occlusion are treated by interventional radiology (IR) via dilation of the pancreaticoduodenal arcade. In patients with dilation of the pancreaticoduodenal arcade on SMA angiograms, IR through this artery may be successful. Here we provide several tips on surmounting these difficulties in IR including transcatheter arterial chemoembolization for hepatocellular carcinoma, an implantable port system for hepatic arterial infusion chemotherapy to treat metastatic liver tumors, coil embolization of pancreaticoduodenal artery aneurysms, and arterial stimulation test with venous sampling for insulinomas.

Introduction

The reported incidence of celiac axis stenosis ranges from 12.5 to 24% in Western populations [1], [2], [3], [4]. Suggested etiologic factors underlying the development of a pancreaticoduodenal artery aneurysm are atherosclerosis, pancreatitis, fibrodysplasia, trauma, and congenital anomalies [5], [6]. The crura on either side of the aortic hiatus are connected by a fibrous arch, the median arcuate ligament (MAL); it usually passes posteriorly and inferiorly to the origin of the celiac axis. Controversy regarding the clinical syndrome continues and varying degrees of compression of the celiac axis by the MAL is an anatomic variant seen in 10–24% of patients [7]. The origin of the celiac trunk migrates caudally during embryogenesis; its location varies from the level of the 11th thoracic to the 1st lumbar vertebra and a high celiac origin or an inferior extension of the MAL results in ligamentous compression of the celiac artery. Varying degrees of celiac trunk compression have been demonstrated angiographically in 13–50% of patients [8], [3], [9]; 1% of abdominal arteriograms detected severe stenosis of the celiac axis [10]. Severe stenosis of the celiac trunk is commonly associated with enlargement of the arteries of the pancreaticoduodenal arcade; they supply the celiac axis via retrograde flow from the superior mesenteric artery (SMA).

In the treatment of hepatocellular carcinoma (HCC), severe stenosis/occlusion of the proximal celiac trunk is one of the limiting factors in selective catheterization of a targeted hepatic artery [11]. Several clinical studies reported transcatheter arterial chemoembolization (TACE) methods in patients with severe stenosis/occlusion of the proximal celiac trunk. Okazaki et al. [12] and Kwon et al. [13] presented their clinical results with TACE procedures performed through the inferior pancreaticoduodenal arcade and the occluded celiac axis. High flow through the pancreaticoduodenal arcade in the presence of celiac artery stenosis or occlusion may be a causative factor in aneurysm formation [14]. Coll et al. [15] suggested transarterial embolization (TAE) as an effective method for the safe exclusion of pancreaticoduodenal artery aneurysms and the retention of the native circulation. Here we submit tips for overcoming difficulties encountered in abdominal interventional radiology (IR) procedures in patients with this medical condition.

Severe stenosis/occlusion of the proximal celiac trunk addressed in this study was attributable to median arcuate ligament compression (MALC), arteriosclerosis, pancreatitis, tumor invasion, and celiac axis agenesis. As the treatment of this condition by interventional procedures is often difficult, we provide tips on surmounting difficulties in the treatment of these patients by IR.

Section snippets

Patient population

Between January 2001 and December 2005, we enrolled 990 patients undergoing 990 abdominal IR procedures. We obtained celiac artery (CA) and superior mesenteric artery (SMA) angiograms in all patients. SMA angiography revealed retrograde opacification of the celiac axis and all its branches through collaterals between the SMA and the celiac axis, a finding indicative of the absence of substantial inflow from the celiac orifice. If we suspected celiac artery stenosis of the proximal celiac trunk

Angiography

For angiography, we preferred the femoral artery as the access site. A 4-Fr vascular sheath (Supersheath; Medikit Co. Ltd., Tokyo, Japan) was placed and secured via the Seldinger technique. The CA and SMA were catheterized with a 4-Fr catheter (RC2 catheter; Medikit), the small arterial branches with a 2.5-Fr microcatheter (Renegerd-18; TARGET, Boston Scientific Corp., Watertown, MA). Placement of the 4-Fr catheter was achieved with the aid of a 0.035-in. diameter torque guidewire (RADIFOCUS;

Computed tomography

In all patients, computed tomography (CT) scans were obtained before abdominal IR to assess celiac axis stenosis/occlusion. We used a 16-row multi-detector CT (MDCT) scanner (Brilliabce CT16, Philips, Netherlands) and a bolus injection of 100 ml of iopromide (Iopamiron 300; Nihon Schering, Osaka) delivered at a rate of 3 ml/s. All images were obtained through the abdomen in a craniocaudal direction; the parameters were 1.5-mm collimation, 17.5-mm/s table speed during a single breath-hold, 15–20 s

Diagnosis of celiac axis stenosis/occlusion

The diagnostic criteria for extrinsic compression of the diaphragm by the MAL were direct visualization of the MAL on MD-CT and detection of the characteristic superior notch formation on celiac angiographs or by the catheter course (Fig. 1a and b). The degree of stenotic changes on celiac artery angiograms increased with expiration and decreased or disappeared with inspiration. A diagnosis of stenosis/occlusion of the celiac axis by invasion of pancreatic cancer was made when soft tissue

Causes of celiac axis stenosis/occlusion

Of the 990 patients, 23 (2.3%) presented with stenosis (n = 18) or occlusion (n = 5) of the proximal celiac trunk; these patients comprised the study population. They were 16 men and 7 women ranging in age from 21 to 84 years (mean 58 years). Table 1 shows the causes of celiac axis stenosis/occlusion. On SMA angiograms, the hepatic and splenic artery could be visualized through a dilation of the pancreaticoduodenal arcade in all patients (Fig. 2a). Stenosis/occlusion of the proximal celiac trunk

TACE for hepatocellular carcinoma

In all 23 patients, SMA angiography showed that a dilated inferior pancreaticoduodenal arcade served as the main feeder of the liver. Of these, 10 underwent TACE for HCC diagnosed by biopsy or clinical findings such as the presence of chronic liver disease related to hepatitis B or C virus, typical CT findings, and an elevated α-fetoprotein level. In 5 of the 10 HCC patients, TACE was through the stenosis of the celiac artery; in the other 5 we performed TACE through the dilated

Discussion

The reported incidence of celiac axis stenosis ranges from 12.5 to 24% in Western populations [1], [2], [3], [4]. In our study population, the incidence of significant celiac axis stenosis/occlusion was 2.3% (23 of 990 patients), probably because our inclusion criteria demanded retrograde opacification of the celiac axis and all its branches through collaterals between the SMA and celiac axis. In the absence of such opacification, interventional procedures present no special problems in

Conclusion

In conclusion, severe stenosis of the proximal celiac trunk occurs due to compression by the median arcuate ligament, arteriosclerosis, pancreatitis, invasion by tumor, and agenesis of the celiac axis and interventional procedures are difficult. In patients with dilatation of the pancreaticoduodenal arcade on SMA angiograms, IR through this artery may be successful.

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Cited by (28)

Spontaneous cessation of postpancreatectomy hemorrhage in a patient with celiac artery stenosis
2022, Radiology Case Reports
Postpancreatectomy hemorrhage (PPH) is a severe complication of pancreatic surgery. This condition often develops on the background of pancreatic fistula. In our report, we demonstrate an unusual case of spontaneous cessation of severe postpancreatectomy common hepatic artery (СHA) hemorrhage after distal pancreatectomy in a patient with celiac artery stenosis (CAS). A 64-year-old male diagnosed with pancreatic tail tumor underwent extended distal pancreatectomy. He developed pancreatic fistula and was discharged with an abdominal drain, and was readmitted with severe postpancreatectomy hemorrhage from a pseudoaneurysm of the CHA. The bleeding stopped spontaneously due to CHA thrombosis. The patient developed no ischemic symptoms. Spontaneous severe postpancreatectomy hemorrhage cessation is an extremely rare phenomenon. Vascular anomalies must be considered when attempting interventional radiology treatment. CHA probably may be sacrificed with no ischemic consequences in case of severe hemorrhage in patients with CAS.
Celiac axis stenosis and digestive disease: Diagnosis, consequences and management
2021, Journal of Visceral Surgery
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature
2018, Pancreatology
Citation Excerpt :
Several aspects should be taken into account when a patient with a CAS requires a pancreatoduodenectomy. First of all, a correct radiological assessment of the anatomical condition, often presenting several vicarious collaterals, requires a correct definition [3]. Second, a well-defined surgical planning, in many cases needing complex vascular reconstructions or venous by-passes, is mandatory [4].
Celiac axis stenosis (CAS) represents an uncommon and typically innocuous condition. However, when a pancreatic resection is required, a high risk for upper abdominal organs ischemia is observed. In presence of collaterals, such a risk is minimized if their preservation is realized. The aim of the present study is to systematically review the literature with the intent to address the routine management of collateral arteries in the case of CAS patients requiring pancreatoduodenectomy.
A systematic search was done in accordance with the PRISMA guidelines, using “celiac axis stenosis” AND “pancreatoduodenectomy” as MeSH terms. Seventy-four articles were initially screened: eventually, 30 articles were identified (n = 87).
The main cause of CAS was median arcuate ligament (MAL) (n = 31; 35.6%), followed by atherosclerosis (n = 20; 23.0%). CAS was occasionally discovered during the Whipple procedure in 15 (17.2%) cases. Typically, MAL was divided during surgery (n = 24/31; 77.4%). In the great majority of cases (n = 83; 95.4%), vascular abnormalities involved the pancreatoduodenal arteries (i.e., dilatation, arcade, channels, aneurysms). Collateral arteries were typically preserved, being divided or reconstructed in only 14 (16.1%) cases, respectively. Severe ischemic complications were reported in six (6.9%) patients, 20.0% of whom were reported in patients with preoperatively unknown CAS (p-value 0.06).
A correct pre-operative evaluation of anatomical conditions as well as a correct surgical planning represent the paramount targets in CAS patients with arterial collaterals. Vascular flow must be always safeguarded preserving/reconstructing the collaterals or resolving the CAS, with the final intent to avoid dreadful intra- and post-operative complications.
Pancreaticoduodenal arcades as salvage route for transarterial embolization of life-threatening hepatic hemorrhage in patients with severe celiac axis stenosis: Case series
2018, International Journal of Surgery Case Reports
Citation Excerpt :
In case of occlusion or severe stenosis of CA, the entire blood supplying the liver is provided by the retrograde arterial flow through PDAs, which induces arterial enlargement leading to prominence of the PDAs on SMA angiogram [18]. Many reports in the literature asserted the importance of PDAs route for different elective transarterial liver treatments in patients having CA stenosis or occlusion, such as chemoembolization, radioembolization and hepatic arterial infusion [2,3,19]. To our knowledge, PDAs are rarely reported as an alternative route in the management of acute hepatic hemorrhage.
Various transarterial embolotherapies for different hepatic etiologies are performed through the celiac axis (CA). However, this pathway is not always patent due to the extensive stenosis or occlusion of the origin of CA. In such situations, the pancreaticoduodenal arcades (PDAs) catheterization is the main alternative to gain access to the hepatic arteries as demonstrated in clinical studies.
We report two cases of life-threating hepatic hemorrhage indicated for emergency transarterial embolization (TAE).
The massive hemorrhage was due to spontaneous rupture of hepatocellular carcinoma (HCC) in the first case and due to post liver blunt trauma in the second case. Owing to severe stenosis of the origin of CA, PDAs were used as a salvage alternative route for emergency TAE of hepatic arteries.
Endovascular management of massive hepatic hemorrhage in cases of inaccessibility to hepatic arteries through CA is a highly challenging situation in which the technical success depends on the operator experience, choice of the material and anatomical knowledge of hepatic arterial collateral supply.
Transcatheter arterial chemoembolization of hepatocellular carcinoma in patients with celiac axis occlusion using pancreaticoduodenal arcade as a challenging alternative route
2017, European Journal of Radiology Open
Citation Excerpt :
Severe stenosis or occlusion of the proximal celiac trunk may be caused by median arcuate ligament compression, arteriosclerosis, pancreatitis, tumor invasion, and celiac axis agenesis. However, clinically significant ischemic bowel disease attributable to celiac axis stenosis/occlusion appears to be rare because the SMA provides for rich collateral circulation [3]. Song et al. [4], concluded that the most common and important collateral vessels from the SMA in patients with celiac axis stenosis are the pancreaticoduodenal arcades and the dorsal pancreatic artery.
Celiac axis occlusion is a challenging condition when catheterization of the hepatic artery is required for chemoembolization of hepatocellular carcinoma (HCC). As a result, the hepatic artery has to be catheterized through the pancreaticoduodenal arcades (PDA) and the gastroduodenal artery (GDA) from the superior mesenteric artery (SMA) which is a tortuous course with acute angles and small caliber branches.
To assess new techniques for facilitating catheterization of the tortuous PDA and the GDA to reach the proper hepatic artery (PHA) and tumor-feeding branches in patients with celiac axis occlusion undergoing chemoembolization of HCC.
The study included eleven patients all admitted to do transcatheter arterial chemoembolization (TACE) for treatment of unresectable HCC. During angiography occlusion of the celiac axis was diagnosed and hypertrophied PDA and GDA was noted in SMA angiography. Catheterization of the PDA was performed by preshaping of the micro-guide wire into a wide curve.
Catheterization of the PHA was a challenge and was achieved by reshaping of the micro-guide wire or by looping technique. TACE was done after super selective catheterization of the tumor feeding artery using a mixture of 50 mg of adriamycin, 7cc of lipiodol and gelfoam.
In the eleven patients with celiac artery occlusion, DSA showed complete celiac axis occlusion in all patients. Collateral arteries supplying the liver were readily evident via PDA and GDA from SMA. Successful catheterization of the PHA was achieved in all patients. Chemoembolization was performed to all patients after super selective catheterization of the feeding artery. Follow-up triphasic CT was performed in all patients, 9 patients showed good lipiodol trapping with no residual tumor enhancement. Two patients required another session of TACE.
Chemoembolization of HCC through the PDA and the GDA using micro-guide wire preshaping technique and the microcatheter looping technique in patients with celiac axis occlusion is a challenging but effective treatment for HCC.
Median arcuate ligament compression of the mesenteric vasculature
2015, Techniques in Vascular and Interventional Radiology
Citation Excerpt :
Some degree of radiographic compression of the celiac axis by the median arcuate ligament, which consists of connective tissue fibers bridging the diaphragmatic crura, is observed in 10%-24% of patients1 (Figs. 1 and 2). Symptomatic compression of the celiac artery by the median arcuate ligament, often referred to as median arcuate ligament syndrome (MALS) or celiac artery compression syndrome, was first described by Harjola in 1963 and is characterized by complaints of abdominal pain, often associated with meals.2 The traditional mainstay of management has been surgical decompression, which is thought to offer symptomatic relief through alleviation of the arterial stenosis as well as division of nerve tissue associated with the celiac ganglion.
Compression of the celiac artery by fibrous bands of the diaphragmatic crura has been associated with gastrointestinal symptoms such as postprandial pain and delayed gastric emptying, a phenomenon known as median arcuate ligament syndrome. The hemodynamic effects of this compression have also been implicated in the development of aneurysms of the celiac artery or its visceral collaterals. Both open surgical decompression and laparoscopic decompression of the celiac artery have proven effective in the treatment of the compressive syndrome. Endovascular stent placement has largely supplanted open surgical reconstruction for residual stenosis following surgical decompression but is not recommended as the sole treatment modality due to high failure rates. Endovascular techniques have also become the mainstay of management of aneurysmal disease associated with celiac artery compression.

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Celiac artery stenosis/occlusion treated by interventional radiology

Abstract

Introduction

Section snippets

Patient population

Angiography

Computed tomography

Diagnosis of celiac axis stenosis/occlusion

Causes of celiac axis stenosis/occlusion

TACE for hepatocellular carcinoma

Discussion

Conclusion

Am Vasc Surg

JVIR

Am Vasc Surg

JVIR

J Vasc Surg

J Vasc Surg

Surgery

Stenosis of the celiac artery

Radiology

The pattern of arteriosclerotic narrowing of the celiac and superior mesenteric arteries

Ann Surg

Splanchnic artery stenosis and occlusion: incidence, arteriographic and clinical manifestations

Radiology

High incidence of celiac axis narrowing in asymptomatic individuals

AJR Am J Roentgenol Radium Ther Nucl Med

Splanchnic artery aneurysms

Arch Surg

A clinicoanatomic study of the arcuate ligament of the diaphragm

Arch Surg

The celiac artery compression syndrome: does it exist?

Surgery

Accentuation of celiac compression by the median arcuate ligament of the diaphragm during deep expiration

Radiology

Severe stenosis of celiac axis: analysis of patients with and without symptoms

Radiology

Hepatic arterial embolization in cases of extensive celiac arterial stenosis

Radiology

Chemoembolization for hepatocellular carcinoma via the inferior pancreaticoduodenal artery in patients with celiac artery stenosis

Acta Radiol

Splanchnic artery aneurysms

Cerebrovascular disease: evaluation with transbrachial intra-arterial digital subtraction angiography using a 4-F catheter

Radiology