Isolated dissection of the celiac trunk and its branches. X-ray computed tomography and angiography findings. A case report

A case of primary dissection of the celiac trunk in a young hypertensive patient is presented. The diagnosis, suspected by ultrasonography, was confirmed by angiography and CT which also allowed a study of the visceral complications. Appropriate surgical treatment was successfully carried out.     

放疗后腹腔动脉和肠系膜上动脉损伤:内支架放置术治疗

目的：本文用于评价血管成形术和内支架的放置在放疗后所致腹腔动脉和肠系膜上动脉损伤的治疗。方法：采用血管成形术和内支架放置的方法治疗2例腹腔运用肠系膜上动脉病变。结果：放疗性动脉性病变为临床治愈，结论：血管成形要和内支架的综合有效治疗放疗所致的动脉性病为，应考虑其为动脉损伤性病变的首选治疗。     

Celiac Trunk Embolization,as a Means of Elongating Short Distal Descending Thoracic Aortic Aneurysm Necks,Prior to Endovascular Aortic Repair

The purpose of this study was to report our experience in elongating short distal necks of descending thoracic aortic aneurysms (DTAAs) by coil embolization of the celiac trunk prior to endovascular aneurysm repair (EVAR). During 6 years seven patients (five men and two women; mean age, 74) who had DTAAs with short distal necks unsuitable for conventional EVAR, and well patent superior and inferior mesenteric arteries based on CT, were treated in one session with EVAR after the celiac trunk was coil embolized to elongate the neck. All patients were followed by CT every 3 months in the first year and every 6 months thereafter. Technical success was achieved in all patients, and no early or late ischemic complications were noted. No procedural complications occurred and good aneurysm sealing was obtained in all patients. Three endoleaks were identified after 3 months (one patient) and 6 months (two patients); all were treated successfully with insertion of an additional stent-graft. In patients with DTAAs who are candidates for EVAR but have short aneurysm distal necks, celiac trunk embolization—only if the superior and inferior mesenteric arteries are patent—is a good and safe way to elongate the neck and enable EVAR.     

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.     

Impact of Multislice CT Angiography on Planning of Radiological Catheter Placement for Hepatic Arterial Infusion Chemotherapy

The objective of this study was to assess prospectively the role of multislice CT angiography (MSCTA) on planning of radiological catheter placement for hepatic arterial infusion chemotherapy (HAIC). Forty-six patients with malignant liver tumors planned for HAIC were included. In each patient, both MSCTA and intra-arterial digital subtraction angiography (DSA) were performed, except one patient who did not undergo DSA. Comparison of MSCTA and DSA images was performed for the remaining 45 patients. Detectability of anatomical variants of the hepatic artery, course of the celiac trunk, visualization scores of arterial branches and interobserver agreement, presence of arterial stenosis, and technical outcome were evaluated. Anatomical variations of the hepatic artery were detected in 19 of 45 patients (42%) on both modalities. The course of the celiac trunk was different in 12 patients. The visualization scores of celiac arterial branches on MSCTA/DSA were 3.0 ± 0/2.9 ± 0.2 in the celiac trunk, 3.0 ± 0/2.9 ± 0.3 in the common hepatic artery, 2.9 ± 0.2/2.9 ± 0.3 in the proper hepatic artery, 2.9 ± 0.3/2.9 ± 0.4 in the right hepatic artery, 2.8 ± 0.4/2.9 ± 0.4 in the left hepatic artery, 2.9 ± 0.2/2.9 ± 0.3 in the gastroduodenal artery, 2.1 ± 0.8/2.2 ± 0.9 in the right gastric artery, and 2.7 ± 0.8/2.6 ± 0.8 in the left gastric artery. No statistically significant differences exist between the two modalities. Interobserver agreement for MSCTA was equivalent to that for DSA. Two patients showed stenosis of the celiac trunk on both modalities. Based on these imaging findings, technical success was accomplished in all patients. In conclusion, MSCTA is accurate in assessing arterial anatomy and abnormalities. MSCTA can provide adequate information for planning of radiological catheter placement for HAIC.     

Treatment of a traumatic celiac trunk detachment by bridging with a stent graft

Traumatic detachment of the celiac trunk from the abdominal aorta is a rare clinical situation, and proper treatment options have not been established. We report a patient with traumatic separation of the celiac trunk treated by bridging with a covered stent between the celiac trunk and abdominal aorta.     

介入治疗孤立性腹腔干夹层4例

【摘要】　目的?探讨介入治疗孤立性腹腔干夹层（IDCA）的效果和安全性。方法?回顾性分析 4例IDCA患者临床和影像学资料。根据孙捷等IDCA分型,Ⅱa型2例,Ⅲb型2例,均因内科保守治疗效果不佳接受介入治疗。2例Ⅱa型患者于腹腔干植入裸支架或覆膜支架1枚,2例Ⅲb型患者于腹腔干及分支内植入覆膜支架和裸支架各1枚。术后给予低分子肝素抗凝3 d,口服氯吡格雷。结果?4例患者手术均成功,术后1周腹痛症状消失,未发生围手术期出血、感染、夹层破裂等并发症。随访6～27个月,4例腹痛症状均未复发,支架均通畅;1例支架移位,3例支架位置良好。结论?支架植入术治疗IDCA安全有效。对低风险IDCA患者首选保守治疗,保守治疗效果不佳者宜选择介入治疗。     

Iatrogenic dissection of the celiac artery and its branches during transcatheter arterial embolization for hepatocellular carcinoma: Outcome in 40 patients

Purpose To study the sequelae of iatrogenic dissection of the celiac axis and its branches in a large patient population. Methods We analyzed 40 patients with hepatocellular carcinoma (HCC) whose celiac artery or its branches were dissected during transcatheter arterial emboiization (TAE) and underwent follow-up angiography within 2 months. Results The two most common sites of dissection were the celiac artery in 13 patients (32.5%) and the proper hepatic artery in 11 patients (27.5%). Follow-up angiography revealed complete recanalization in 32.5% (13/40), irregularity and narrowing of the lumen in 40% (16/40), and complete obstruction in 27.5% (11/ 40). Therefore, 72.5% (29/40) of the dissected arteries recanalized. Pseudoaneurysm formation of the dissected artery was observed in 32.5% (13/40). Subsequent TAE was possible via the dissected arteries in 79% (27/34) of patients in this series. Conclusion Iatrogenic dissection of the celiac and proximal hepatic arteries heals spontaneously in the majority of patients, and in most instances allows subsequent TAE.     

Celiac Injury Due to Arcuate Ligament: An Endovascular Approach

Celiac trunk injures are rare events, with high mortality rates and difficult management. Endovascular treatment may be considered to avoid bleeding. We report a case of severe bleeding in a 37-year-old man resulting from celiac trunk stretching after a motorcycle crash. Because direct celiac trunk catheterization was not possible, a retrograde catheterization of the common hepatic artery was performed via the superior mesenteric artery. Two vascular plugs (type IV) were released, and the exclusion of the celiac trunk origin was completed with the deployment of an aortic cuff. The patient’s clinical condition immediately improved, and after 6 months’ follow-up, imaging confirmed the complete exclusion of the celiac trunk.     

血管内支架在放疗后动脉损伤中的应用

目的：用于评价内支架放置术在放疗后所致动脉疾病的治疗,及靶血管内内支架的长期支撑开放作用。方法;１３个内架放置于８个放疗后动脉性疾病的患者,其分别治疗血管闭塞３例,动脉瘤１例,残存狭窄２例,多发狭窄１例,球囊成形术后再发狭窄１例,所有病例均用ＣＴ扫描和／或多普勒超声检查,观察内支架及其靶血管内和内支架内的血流情况,结果：介入方法成功治疗８例放疗后所致动脉疾病的患者,５例动脉病变基本消失,追踪２年（     

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.     

肠系膜上动脉病变 MSCTA 诊断价值

目的：探讨多层螺旋 CT 血管成像(MSCTA)诊断肠系膜上动脉(SMA)病变临床价值。方法回顾性分析40例 SMA病变患者 MSCTA 图像特点,运用容积再现(VR)、多平面重组(MPR)、曲面重组(CPR)及最大密度投影(MIP)等多种后处理重建技术。结果SMA 缺血16例,包括 SMA 急性闭塞8例,其中并发小肠缺血性坏死1例并行坏死小肠切除术。SMA 慢性闭塞8例;孤立性 SMA 夹层10例;SMA 真性动脉瘤7例,感染性心内膜炎相关假性动脉瘤1例;SMA 溃疡3例,其中1例合并肠系膜下动脉(IMA)重度狭窄;腹腔干重度狭窄2例;IMA 闭塞1例。本组40例患者可见 SMA 疾病相关侧支循环13例,4例见于 SMA 慢性闭塞,3例见于 SMA 急性闭塞,1例见于孤立性 SMA 夹层,1例见于 SMA 假性动脉瘤,2例分别见于 IMA 狭窄和闭塞。2例见于腹腔干重度狭窄。其中包括胰十二指肠前、后动脉弓3例,胰背动脉侧支2例、Riolan 弓10例。结论MSCTA 可以清晰观察SMA 各类病变、侧支循环开通情况以及评估肠腔缺血状态。     

Balloon-assisted coil embolization of the celiac trunk before endovascular aortic repair of thoracoabdominal aortic aneurysm

Purpose

Celiac trunk coil embolization before thoracic endovascular aneurysm repair (TEVAR) of a thoracoabdominal aortic aneurysm involving the celiac trunk can prevent type II endoleaks. One disadvantage of conventional coil embolization is the risk of coil displacement. We performed coil embolization under balloon occlusion of the celiac trunk to address this issue.

Materials and methods

Between December 2008 and January 2011, 5 patients (3 men and 2 women, mean age 76 years) were included in this study. For all patients, after confirming the collateral blood flow from the superior mesenteric artery via the pancreaticoduodenal arcades by using the balloon occlusion test, celiac trunk coil embolization proceeded under balloon occlusion of the proximal part of the celiac trunk.

Results

Balloon-assisted coil embolization of the celiac trunk was completed for all patients without any complications. All coils were deployed as planned in the short segment of the celiac trunk without displacement. Coil migration, ischemic complications, and endoleaks via the celiac trunk did not arise in any of the patients over a follow-up period of 77–637 (mean 258) days.

Conclusions

Balloon-assisted coil embolization of the celiac trunk before TEVAR could be a feasible treatment option for suitable patients.     

不同固定方式对兔肝动脉介入插管的影响

【摘要】　目的?探讨两种不同固定方式对兔肝动脉插管技术难度的影响。方法?30只新西兰大白兔固定于自制木质平板手术台上行CT增强扫描,获取动脉期腹腔干和腹主动脉信息,CT多曲面重建获取腹腔干及其下层面腹主动脉间夹角;采用改良固定方式固定30只实验兔并获取腹腔干和腹主动脉间夹角。比较两种固定方式下兔腹腔干和腹主动脉夹角的差异。将30只实验兔随机分为实验组与对照组,实验组以改良固定方式固定兔,行股动脉穿刺肝动脉插管,对照组兔固定于木质平板手术台行肝动脉插管,获取并比较两组实验兔手术成功率、手术操作时间及手术并发症发生率。结果?平板固定方式下腹腔干和腹主动脉间夹角为117.93°±13.42°,改良固定方式下夹角为144.40°±14.76°（P＜0.05）;对照组肝动脉插管手术成功率为66.7%（10/15）,实验组为100%（15/15）（P＜0.05）;对照组血管夹层发生率为26.7%（4/15）,实验组为0%（P＜0.05）;对照组平均手术操作时间为（504.40±47.25） s,实验组为（88.87±14.99） s（P＜0.05）。结论?改良固定方式可改变兔腹腔干和腹主动脉夹角,有效降低肝动脉插管的技术难度,降低并发症发生率,缩短手术时间,提高操作成功率。     

Mycotic Aneurysm of the Celiac Trunk: From Early CT Sign to Rupture

We present a case of the rapid development and rupture of a mycotic celiac trunk aneurysm. Initially on multislice computed tomography (ms-CT) there was a normal celiac trunk with minimal haziness of the surrounding fat. Only 2 weeks later the patient went into hypovolemic shock due to a ruptured celiac aneurysm. Although aneurysms of the visceral arteries are rare, they are of major clinical importance as they carry a life-threatening risk of rupture. This case illustrates the use of ms-CT in detecting and evaluating visceral aneurysms, in order to prevent emergency operation.     

Dual-phase 3D CT angiography during a single breath-hold using 16-MDCT: assessment of vascular anatomy before laparoscopic gastrectomy

OBJECTIVE: In this study, we evaluated the efficacy of dual-phase 3D CT angiography (CTA) during a single breath-hold using 16-MDCT in the assessment of vascular anatomy before laparoscopic gastrectomy. MATERIALS AND METHODS: The study involved 20 consecutive patients (10 men, 10 women; mean age, 59 years) scheduled for laparoscopic gastrectomy for the treatment of early gastric cancer. A dual-phase contrast-enhanced CT scan using 16-MDCT was obtained before laparoscopic gastrectomy. After rapid infusion of a nonionic contrast agent, arterial and venous phase scans were obtained serially with an interval of 15 sec during a single breath-hold of 31 sec. Three-dimensional CTA images in the arterial phase (3D CT arteriography) and venous phase (3D CT venography) were individually reconstructed using the volume-rendering technique, and then the images were fused together. We evaluated the detectability of the celiac trunk, left gastric artery (LGA), right gastric artery (RGA), left gastric coronary vein (LCV), Henle's gastrocolic trunk, right gastroepiploic vein (RGEV), and accessory right colic vein on 3D CTA to compare with surgical findings. RESULTS: In all 20 patients, 3D CT arteriography and venography clearly showed the celiac trunk, LGA, RGA, Henle's gastrocolic trunk, RGEV, and accessory right colic vein, which were correctly identified during surgery. The branching pattern of the celiac trunk was classified as Michels type I in 19 patients and Michels type II in one patient. Imaging showed the RGA originating from the proper hepatic artery (PHA) in nine patients; from the gastroduodenal artery (GDA) in seven patients; and from the left hepatic artery (LHA) in four patients. In 12 patients, the LCV joined the portal vein (PV) and in eight, the splenic vein (SV). In all patients, the accessory right colic vein joined the RGEV, and Henle's gastrocolic trunk proximal to the joining point flowed to the superior mesenteric vein (SMV). In all 20 patients, the fused image simultaneously showed arteries and veins around the stomach, with no mismatch between the arterial and venous phase images. In 10 patients, the LCV joined the PV after running along the dorsal side of the PHA, common hepatic artery (CHA), or splenic artery (SA). In eight patients, the LCV joined the SV after running along the ventral side of the PHA, CHA, or SA. In two patients, the LCV joined the PV after running along the ventral side of the CHA, which correlated with the surgical findings. Both the sensitivity and positive predictive values of 3D CTA revealed 100% correct identification of the celiac trunk, LGA, RGA, LCV, Henle's gastrocolic trunk, RGEV, and accessory right colic vein. CONCLUSION: Dual-phase 3D CTA using 16-MDCT clearly revealed individual arteries and veins around the stomach before laparoscopic gastrectomy. The fused image of 3D CT arteriography and venography during a single breath-hold enabled the simultaneous assessment of arteries and veins before laparoscopic gastrectomy.     

An Unusual Case of Stent Migration After Celiac Trunk Endovascular Revascularization

A 61-year-old woman underwent celiac trunk stenting to treat abdominal angina. Three months later, she was readmitted for recurrent symptoms. Computed tomography control revealed the migration of the stent into the splenic artery. No sign of vessel injury or end-organ ischemia was detected. Repeat stenting of the celiac trunk was performed; the postoperative course was uneventful. 12 months later, the patient was asymptomatic with the second stent in its correct position, and she was asymptomatic for mesenteric ischemia.     

血管成形术和内支架置入术对放射治疗后动脉损伤的治疗

目的评价经皮穿刺血管成形术和内支架置入术在放射治疗（简称放疗）后所致动脉疾病的治疗,及靶血管和内支架的长期支撑开放作用。方法１４例患者,因为放疗所致１８处动脉性病变,而给予血管球囊成形术治疗。并将１３个内支架置入于８例患者,分别治疗血管闭塞３例,动脉瘤１例,残存狭窄２例,多发狭窄１例,球囊成形术后再发狭窄１例。所有病例均用ＣＴ扫描和（或）多普勒超声检查,观察内支架及其靶血管内的血流情况。结果血管成形术成功治疗１４例,其中８例患者在动脉病变处置入内支架。随访８个月至５年,１１例动脉病变基本消失,血管造影示狭窄＜２０％,临床症状完全解除,３例狭窄＜３０％,临床症状改善。结论单一的血管成形术以及多技术综合运用,可有效治疗放疗所致的动脉性病变,应考虑其为动脉损伤性病变的首选治疗方法     

Endovascular Treatment of Hemoptysis by Abnormal Systemic Pulmonary Artery Supply

We report the case of a 29-year-old man with hemoptysis. The patient came to the emergency department, where a laboratory test and chest radiograph were reported as normal. The following day the patient again had hemoptysis, though less than previously. He reported no chest pain, dyspnea, fever, catarrh, changes in urine or feces, contact with patients with bacillus disease or constitutional symptoms. Doppler ultrasound of the chest showed right basal parenchymatous condensation containing a vessel with arterial flow (in the opposite direction to the aortic flow) compatible with an aberrant vessel, possibly a sequestration, leaving the aorta above the celiac trunk. Because of the findings of the chest echogram and magnetic resonance study, thoracoabdominal computed tomography angiography was undertaken; this showed right basal condensation and an anomalous vessel originating 1 cm above the celiac trunk, supplying the right lower lobe. An aortic and pulmonary arteriogram via an arterial and right femoral vein approach confirmed the findings. The patient was treated successfully with percutaneous embolization with coils. The relevant literature is reviewed.     

Spontaneous isolated dissection of the celiac artery: CT findings in adults

OBJECTIVE: Our objective was to describe the CT features of spontaneous isolated celiac artery dissection in a series of six otherwise healthy patients with acute abdominal pain. CONCLUSION: Although once believed rare, isolated spontaneous celiac artery dissection should be considered in the diagnosis of acute abdominal pain, especially in middle-aged adults.