Symptomatic Celiomesenteric Trunk: Variable Presentations and Outcomes in 2 Patients

Abstract

M esenteric ischemia can have a variety of presentations, ranging from classic and predictable to unusual and occult. For instance, a visceral vascular obstruction from a cardioembolic source tends to be acute and spares the proximal splanchnic vasculature. In contrast, when atherosclerotic disease develops at the origins of the aortic branches, it is typically preceded by chronic symptoms.1,2 Usually, the redundancy of the vascular collaterals between the fore-and midgut, which involves structures such as the pancreaticoduodenal arcade and the arc of Buhler, provides protection against ischemia. However, patients with anatomic variations-such as a celiomesenteric trunk (CMT), in which the superior mesenteric artery (SMA) originates from the celiac axis (CA) (Fig. 1)-lack this protection. In these patients, successful diagnosis and management depends on astute interpretation of radiologic images (usually computed tomographic angiograms [CTAs]).3,4 Misdiagnosis can lead to prolonged suffering or death.We present the cases of 2 patients with symptoms of mesenteric ischemia in whom we diagnosed CMT. Their cases illustrate the different courses of disease and outcomes in this population. Case Reports Patient 1Chronic Mesenteric Ischemia. A 57-year-old woman presented with a 5-year history of severe, postprandial abdominal pain that had led to a fear of eating and a 40-lb weight loss. Over the years before admission, she had undergone endoscopic and ultrasonographic evaluations with unremarkable results. Additionally, she had undergone prolonged empiric treatment for peptic ulcer disease, which was unsuccessful in controlling her symptoms. She had been referred to our clinic after an outpatient CTA revealed no ventral branch in the anticipated location on the SMA, occlusion of the proximal CA, and a CMT (Fig. 2A). The inferior mesenteric artery (IMA) was enlarged (6 mm), as was a tortuous marginal arcade (up to 7.5 mm) (Fig. 2B). Elective surgical exploration confirmed the presence of CMT and revealed compression of the origin of the celiac trunk by the median arcuate ligament (MAL). There were also chronic fibrotic changes in the CMT. Even after lysis of the crural fibers, the CMT remained occluded, and Doppler ultrasound testing of the structure produced poor signals. Therefore, we performed an aortomesenteric bypass with a 6-mm Dacron graft to the confluence of branches originating from the CMT. Exploration of the remainder of the abdomen confirmed a markedly hypertrophic marginal arcade and its Case Reports

Successful endovascular treatment of acute mesenteric and hepatic ischemia in patient with celiomesenteric trunk occlusion

“…A replaced common hepatic artery (RCHA) from the superior mesenteric artery (SMA) is one of the variants of the celiomesenteric trunk and is rare, occurring in 1.13% of 19,013 cases in the largest systematic review of the literature. 1 Patients with an RCHA can require vascular intervention for acute and chronic ischemia, 2 , 3 , 4 , 5 , 6 , 7 aneurysms, 8 , 9 dissection, 10 and median arcuate ligament syndrome. 8 Reports of patients with mesenteric ischemia in the setting of a celiomesenteric trunk variant have described excellent clinical results with thoughtful and timely open and endovascular intervention.…”

“… 4 , 5 , 9 , 11 Other reports have acknowledged that mesenteric ischemia in a patient with a celiomesenteric trunk presents diagnostic and therapeutic challenges but that delay in definitive treatment has lethal consequences. 3 , 6 , 12 We report the case of a 73-year-old woman with acute occlusion of her celiomesenteric trunk who underwent successful endovascular repair. She was cachectic, with months of food fear and weight loss, and presented with severe acute abdominal pain.…”

“…The terms currently used in the literature include replaced common hepatic artery (or RCHA), celiomesenteric trunk, celiacomesenteric trunk, and quadrification, among others. 3 , 6 , 7 , 9 , 11 , 13 The aberrant origin of some of these arteries is likely related to the persistence of vitelline arteries during embryologic development. 14 Previous classification systems of these anomalies failed to provide the level of anatomic detail required by surgeons and interventionists planning revascularization.…”