Median arcuate ligament syndrome diagnosis on Computed Tomography: what a radiologist needs to know

Median arcuate ligament syndrome or celiac artery compression syndrome is one of the abdominal vascular compression syndromes due to compression of proximal celiac artery by the median arcuate ligament. The median arcuate ligament unites diaphragmatic crura on either side at the level of aortic hiatus. The ligament has a low insertion causing compression of the celiac artery resulting in clinical symptoms of postprandial pain and weight loss. It is a rare syndrome, detected incidentally on routine Computed Tomography abdomen and pelvis studies. We present a rare case of a 35-year-old female who presented with abdominal pain. She was evaluated by Computed Tomography scan of the abdomen and pelvis. Ultrasound Doppler of mesenteric vasculature helped detect celiac artery stenosis. A referral to the vascular surgery department was made; however, the patient was managed conservatively.     

Two cases of pancreaticoduodenal aneurysm with median arcuate ligament syndrome treated with coil embolization and median arcuate ligament incision

Median arcuate ligament syndrome is a clinical condition in which the median arcuate ligament causes compression and narrowing of the celiac artery. It has been reported that collateral pathways, which is developed by the decrease of blood flow from the celiac artery, facilitates the formation of aneurysms. Aneurysms around the pancreas in particular require aggressive therapeutic intervention, because a rupture can be fatal. We herein report two cases of pancreaticoduodenal aneurysms associated with median arcuate ligament syndrome treated by coil embolization and median arcuate ligament incision. Case 1 required a hybrid procedure in which median arcuate ligament incision and coil embolization were performed simultaneously. In Case 2, the median arcuate ligament incision was performed about 3 months after emergency endovascular hemostasis for hemorrhagic duodenal ulcer. In both cases, there were no major postoperative complications and no recurrence of aneurysm. Median arcuate ligament incision may be effective to prevent organ ischemia and aneurysm recurrence after coil embolization of intra-abdominal aneurysms associated with median arcuate ligament syndrome.     

Embolization in a patient with ruptured anterior inferior pancreaticoduodenal arterial aneurysm with median arcuate ligament syndrome

In median arcuate ligament syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, causing abdominal angina. Aneurysm may be formed in arteries of the pancreas and duodenum due to a chronic increase in blood flow from the superior mesenteric artery into the celiac arterial region. We report a patient saved by embolization with coils of ruptured aneurysm that developed with markedly dilated anterior inferior pancreaticoduodenal artery due to median arcuate ligament syndrome.     

Clinical and Radiologic Review of Uncommon Cause of Profound Iron Deficiency Anemia: Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome is an anatomic and clinical entity characterized by dynamic compression of the proximal celiac artery by the median arcuate ligament, which leads to postprandial epigastric pain, vomiting, and weight loss. These symptoms are usually nonspecific and are easily misdiagnosed as functional dyspepsia, peptic ulcer disease, or gastropathy. In this report, we presented a 72-year-old male patient with celiac artery compression syndrome causing recurrent abdominal pain associated with gastric ulcer and iron deficiency anemia. This association is relatively uncommon and therefore not well determined. In addition, we reported the CT angiography findings and three-dimensional reconstructions of this rare case.     

Marked increase in flow velocities during deep expiration: A duplex doppler sign of celiac artery compression syndrome

Symptoms of chronic mesenteric ischemia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament. RID=" ID=" <E5>Correspondence to:</E5> A. Erden, M.D., Hafta sokak. 23/6, Gaziosmanpa&scedil;a, 06700 Ankara, Turkey     

Ligamentous compression of the celiac axis: CT findings in five patients

Compression of the celiac trunk by the median arcuate ligament of the diaphragm is an uncommon angiographic and surgical finding that rarely may be symptomatic. We retrospectively reviewed contrast-enhanced abdominal CT scans in five patients with severe ligamentous compression of the celiac axis, confirmed by surgery and/or angiography, and compared the findings with those of enhanced scans of 100 consecutive patients without known ligamentous compression. In all five patients with ligamentous celiac artery compression, CT showed effacement or narrowing of the celiac trunk by an anterior soft-tissue band. Dilated peripancreatic collateral vessels were seen in four cases, and poststenotic dilatation of the distal celiac trunk was seen in two cases. The normal appearance of the vasculature was seen in the majority (76%) of the 100 control subjects, but in eight patients the celiac origin was obscured on CT scans, and in 16 patients the celiac trunk appeared narrow or effaced. Our experience suggests that severe ligamentous celiac artery compression can be identified on CT. However, the isolated CT finding of effacement or obscuration of the celiac axis occurs sufficiently often in normal patients that it is not adequate evidence to establish the diagnosis of celiac artery compression.     

Analysis of five cases of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament

AIM: To elucidate the mechanism of occurrence of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament, and also to discuss the management for this relatively rare condition. MATERIALS AND METHODS: Five consecutive cases of splanchnic artery aneurysm associated with coeliac axis stenosis due to compression by the median arcuate ligament, including four cases of pancreaticoduodenal artery aneurysm and one case of epiploic artery aneurysm, were investigated. These cases were collected over a 5-year period in our local and affiliated hospitals. Among these five cases, three were discovered because of rupture of the aneurysm, and two were found incidentally in annual medical check-ups. RESULTS: In all cases, conspicuously developed collateral arteries, which were of the dilated pancreaticoduodenal arcade and its branches, were conspicuously found on digital subtraction angiography of the superior mesenteric artery. The findings suggested that haemodynamic changes in the splanchnic arterial networks (an increase in blood flow mainly through the pancreaticoduodenal arcade), were the possible cause of the corresponding aneurysms. CONCLUSION: Compression by the median arcuate ligament might be a frequent cause of splanchnic aneurysm, which, on rupture of the aneurysm, could be life-threatening.     

Quantitative parameters of image quality in 64-slice computed tomography angiography of the coronary arteries

We explored quantitative parameters of image quality in consecutive patients undergoing 64-slice multi-detector computed tomography (MDCT) coronary angiography for clinical reasons. Forty-two patients (36 men, mean age 61 +/- 11 years, mean heart rate 63 +/- 10 bpm) underwent contrast-enhanced MDCT coronary angiography with a 64-slice scanner (Siemens Sensation 64, 64 mm x 0.6 mm collimation, 330 ms tube rotation, 850 mAs, 120 kV). Two independent observers measured the overall visualized vessel length and the length of the coronary arteries visualized without motion artifacts in curved multiplanar reformatted images. Contrast-to-noise ratio was measured in the proximal and distal segments of the coronary arteries. The mean length of visualized coronary arteries was: left main 12 +/- 6 mm, left anterior descending 149 +/- 25 mm, left circumflex 89 +/- 30 mm, and right coronary artery 161 +/- 38 mm. On average, 97 +/- 5% of the total visualized vessel length was depicted without motion artifacts (left main 100 +/- 0%, left anterior descending 97 +/- 6%, left circumflex 98 +/- 5%, and right coronary artery 95 +/- 6%). In 27 patients with a heart rate < or = 65 bpm, 98 +/- 4% of the overall visualized vessel length was imaged without motion artifacts, whereas 96+/-6% of the overall visualized vessel length was imaged without motion artifacts in 15 patients with a heart rate > 65 bpm (p < 0.001). The mean contrast-to-noise ratio in all measured coronary arteries was 14.6 +/- 4.7 (proximal coronary segments: range 15.1 +/- 4.4 to 16.1 +/- 5.0, distal coronary segments: range 11.4 +/- 4.2 to 15.9 +/- 4.9). In conclusion, 64-slice MDCT permits reliable visualization of the coronary arteries with minimal motion artifacts and high CNR in consecutive patients referred for non-invasive MDCT coronary angiography. Low heart rate is an important prerequisite for excellent image quality.     

不典型主动脉夹层MSCT血管成像及临床应用(附8例报道)

目的：探讨MSCT对不典型主动脉夹层的诊断价值。方法：回顾性分析8例不典型主动脉夹层的MSCT血管成像及其重组影像资料。结果：VR、MPR重组图像均清晰显示出升主动脉、主动脉弓、降主动脉、腹主动脉、双侧髂总动脉、双侧髂内外动脉以及腹腔动脉干、肠系膜上动脉、双侧肾动脉主要分支的血管,图像清晰,血管对比明显,血管边缘无阶梯状改变;8例患者中有5例表现为壁内血肿,3例为无回腔性沟通。结论：MSCT血管成像技术可以在无创或微创的情况下清晰显示不典型主动脉夹层,为临床的诊断和治疗提供有价值的信息。     

Celiac Axis Stenosis: Incidence and Etiologies in Asymptomatic Individuals

Objective

To determine the incidence and etiologies of celiac axis stenosis in asymptomatic individuals.

Materials and Methods

This prospective study involved 400 consecutive patients (male: 319, female: 81) referred to us for celiac arteriography between April and July 1999. When celiac axis branches were opacified by collateral circulation during superior mesenteric arteriography, the presence of celiac axis stenosis was suspected; lateral projection celiac arteriography was performed and the pressure gradient was measured. The indicators used to determine whether or not celiac axis stenosis was significant were luminal narrowing of more than 50% and a resultant pressure gradient of at least 10 mmHg. Its etiology was determined on the basis of angiographic appearances and CT findings.

Results

Twenty-nine patients (7.3%) had celiac axis stenosis. The etiology of the condition was extrinsic compression due to the median arcuate ligament in 16 patients (55%) and atherosclerosis in three (10%), while in ten (35%) it was not determined. The incidence of celiac axis stenosis did not vary significantly according to sex, age and the presence of calcified aortic plaque representing atherosclerosis.

Conclusion

The incidence of hemodynamically significant celiac axis stenosis in this asymptomatic Korean population was 7.3% and the most important etiology was extrinsic compression by the median arcuate ligament of the diaphragm. Atherosclerosis was only a minor cause of the condition.     

Clinical and multidetector computed tomography findings of patients with median arcuate ligament syndrome

ObjectivesThe present study aimed to present the clinical and multidetector computed tomography (MDCT) findings of patients who were diagnosed with the median arcuate ligament (MAL) syndrome on MDCT retrospectively.MethodsSeven hundred forty-four patients in whom MDCT angiography was performed were retrospectively analyzed for investigating incidental MAL syndrome.ResultsTwenty-one patients were shown to have MAL syndrome. Of 21 patients, 18 with MAL syndrome were asymptomatic. Three patients had some symptoms. On MDCT angiography, proximal narrowing of the arteries was observed in 21 patients.ConclusionsMDCT is a minimally invasive and useful tool for the diagnosis of MAL syndrome.     

Role of multidetector computed tomography (MDCT) angiography in preoperative assessment of coarctation of the aorta in pediatric patients and young adults

IntroductionAim of this work is to assess the reliability of 64-slice multidetector computed tomographic (MDCT) angiography for the preoperative assessment of coarctation of the aorta in pediatric patients and young adults.Material and methodsTwenty eight patients with clinical suspicion of coarctation of the aorta who underwent both Doppler echocardiography and MDCT angiography were included in the study. MDCT angiography findings were compared with both Doppler echocardiography and surgical results.ResultsThe overall sensitivity of three-dimensional MDCT angiography for diagnosis of the coarctation of the aorta was (100%) which was higher than that of Doppler echocardiography (91%).The overall sensitivity of MDCT angiography for the assessment of cardiac defects was (88%) which was lower than that of Doppler echocardiography (100%).ConclusionWe concluded that MDCT angiography with multiplanar and three dimensional techniques can be considered the modality of choice for preoperative assessment of coarctation of the aorta in pediatric patients and young adults.     

Tumor tissue characterization evaluating the luciferase activity under the control of a hsp70 promoter and MR imaging in three tumor cell lines

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.     

Is celiac artery compression syndrome genetically inherited?: A case series from a family and review of the literature

The median arcuate ligament is a tendinous arch joining the two medial borders of the diaphragm crura together. In 13-50% of asymptomatic subjects it is responsible for significant angiographic celiac trunk compression. The significance of median arcuate ligament-associated celiac artery compression has been a source of some controversy in the past literature, and the etiology remains unclear. We report here a case series from a family that was diagnosed by the use of multidetector computed tomography. The observation of this syndrome in a family suggests that the responsible anatomic relationships are congenital and may be genetically inherited.     

Celiac artery compression syndrome: diagnosis with multislice CT

Celiac artery compression syndrome is a rare disorder characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs. In this syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration. We report here 3 such cases that were diagnosed by the use of multislice computed tomography.     

Abdominal aortic aneurysm: pretherapy assessment with dual-slice helical CT angiography

OBJECTIVE: The purpose of this study was to evaluate dual-slice helical CT in the pretherapy assessment of abdominal aortic aneurysms. SUBJECTS AND METHODS: Dual-slice helical CT angiography was performed in 47 consecutive patients (mean age, 59 years) with abdominal aortic aneurysm to determine whether we could then evaluate the extent of aneurysm and see associated renal, celiac, mesenteric, and iliofemoral artery disease. Results were compared with those of digital subtraction angiography (n = 47) and surgery (n = 37). RESULTS: The proximal and distal extents of abdominal aortic aneurysm correlated well with surgical findings. Dual-slice helical CT showed all main (n = 102) and accessory (n = 13) renal arteries with a sensitivity of 91% and a specificity of 100% for revealing associated renal artery stenosis exceeding 50%. Sensitivity and specificity of dual-slice helical CT for revealing stenosis exceeding 75% in celiac and superior mesenteric arteries were both 100%. Three of four iliofemoral artery stenoses and two occlusions of the common iliac artery were revealed by dual-slice helical CT. CONCLUSION: Helical CT angiography with dual-slice scanning is a useful and minimally invasive technique that can provide with high accuracy all the necessary information for treatment of abdominal aortic aneurysm.     

Volume-rendered multidetector CT angiography: noninvasive follow-up of patients treated with renal artery stents

OBJECTIVE: The purpose of our study was to evaluate the role of multidetector CT (MDCT) angiography with volume rendering for estimating the patency of renal artery stents. SUBJECTS AND METHODS: In 16 patients, 16 renal artery stents were evaluated with MDCT renal angiography and digital subtraction angiography (DSA). CT data were evaluated using multiplanar volume reformations and the volume-rendering algorithm with three different volume-rendered parameter settings (low-to-high, high-to-low, and high-low-high opacity transfer functions: VR(LH), VR(HL), and VR(VE), respectively). Targeted images of each stent were rendered in paraaxial and paracoronal planes and were interactively interpreted. The overall restenosis severity was measured on postprocessed paraaxial and paracoronal images and compared with that obtained on DSA using linear regression analysis. Image quality and lumen delineation on rendered images were also compared using Wilcoxon's signed rank test. RESULTS: Eight restenoses were identified on DSA. Correlations between restenosis severity measured with DSA and those measured with MDCT were significant (p < 0.001). Volume rendering with VR(HL) allowed the best correlation with DSA (reviewer 1, r(2) = 0.86; reviewer 2, r(2) = 0.94) and was significantly better than multiplanar volume reformations (p = 0.028). Overall image quality was high with all rendering techniques and with no significant differences (p > 0.59, for all comparisons). Stent lumen was well delineated with volume-rendering modalities; however, VR(HL) was significantly better than VR(LH) (p = 0.033). CONCLUSION: Volume-rendered MDCT angiography enabled high-quality three-dimensional reproducible evaluation of the patency of implanted renal artery stents. Volume rendering with VR(HL) achieved the best performance.     

Transcatheter arterial chemoembolization for hepatocellular carcinomas in patients with celiac axis occlusion

PURPOSE: To verify the hypothesis that most instances of celiac axis occlusion in patients with hepatocellular carcinoma (HCC) are caused by diaphragmatic compression and, therefore, transcatheter arterial chemoembolization (TACE) can be performed through the compressed lumen of the celiac axis. MATERIALS AND METHODS: The authors attempted to perform TACE in 36 consecutive patients with HCC and celiac axis occlusion. Spiral computed tomographic (CT) images were available in 26 patients. Initially, catheterization of the hepatic arteries was attempted through the occluded celiac axis. If it failed, catheterization was performed through the pancreaticoduodenal arcades. The causes of celiac axis occlusion were evaluated based on spiral CT and angiographic findings, access routes, technical success rates, and related complications in superselective catheterization of hepatic arteries. RESULTS: Among the 26 patients who underwent spiral CT, diaphragmatic compression of the celiac axis was demonstrated in 23. Selective catheterization of hepatic arteries was possible through the occluded celiac axis in 23 patients (64%). In nine (25%) of the remaining 13 patients, TACE was performed through the dilated pancreaticoduodenal arcades from the superior mesenteric artery. As a procedure-related complication, celiac axis dissection occurred in one patient (3%). CONCLUSION: Most patients with celiac axis occlusion had arcuate ligament compression. In TACE, the celiac artery occlusion could be traversed directly and this should be the initial approach.     

MDCT evaluation of thoracic aortic anomalies in pediatric patients and young adults: comparison of axial, multiplanar, and 3D images

OBJECTIVE: The objective of our study was to compare accuracies of axial, multiplanar, and 3D volume-rendered images in the diagnosis of thoracic aortic anomalies in pediatric patients and young adults. MATERIALS AND METHODS: Fourteen patients, 17 days to 20 years old, with thoracic aortic anomalies underwent MDCT using axial, multiplanar, and 3D volume-rendering imaging. All images were reviewed by three radiologists for position of the aortic arch, coarctation, vascular compression of the airway, collateral vessel formation, and aortopulmonary shunts (patent ductus arteriosus). Final diagnosis was determined by echocardiography, conventional angiography, bronchoscopy, or surgery. Diagnostic accuracy, sensitivity, and interobserver agreement were evaluated. RESULTS: Average accuracies (average of the three observers for a correct diagnosis) were greater than or equal to 96% for diagnoses of aortic position and airway narrowing on all image types. For the diagnosis of coarctation, average sensitivities (average of the three observers for a true diagnosis) were 73% for axial, 100% for multiplanar, and 100% for 3D volume-rendered images. For the diagnosis of patent ductus arteriosus, average sensitivities were 78% for axial, 94% for multiplanar, and 89% for 3D volume-rendered images. No patients in this study had collateral vessel formation. For the diagnosis of absence of collateral vessel formation, average sensitivities were 100% for axial, 100% for multiplanar, and 100% for 3D volume-rendered images. There were no significant statistical differences in diagnostic performances, agreement with truth, or confidence scores among observers or imaging formats (p > 0.05). CONCLUSION: Axial, multiplanar, and 3D volume-rendered images serve equally well as methods for assessing the side of the aorta to diagnose anomalies. For evaluation of coarctation and patent ductus arteriosus, multiplanar and 3D volume-rendered images perform slightly better than axial images.     

Multidetector computed tomography (MDCT) angiography of thoracic aortic coarctation in pediatric patients: Pre-operative evaluation

Objective

The purpose of this study was to evaluate the reliability of 64-slice multi-detector computed tomographic (MDCT) angiography in pre-operative assessment of coarctation of thoracic aorta of pediatric age groups using 64 multislice CT scanner.

Materials and methods

Twenty four patients with clinical suspicion of coarctation of the thoracic aortic anomalies who underwent both Doppler echocardiography and MDCT angiography were included in the study. MDCT angiography findings were compared with both Doppler echocardiography and surgical results.

Results

The overall sensitivity of the MDCT angiography for diagnosis of the extra-cardiac aortic anomalies was 100% which was higher than that of Doppler echocardiography (92%). The overall sensitivity of MDCT angiography for the assessment of cardiac defects was 85% which was lower than that of Doppler echocardiography (100%).

Conclusion

We concluded that MDCT angiography with multiplanar and three dimensional techniques can be considered the modality of choice for pre-operative assessment of coarctation of the thoracic aorta in pediatric patients.