Celiomesenteric trunk: New classification based on multidetector computed tomography angiographic findings and probable embryological mechanisms

Outcomes of patients treated with double-wide scallop vs fenestrations for celiac artery incorporation during repair of complex abdominal aortic aneurysms

OBJECTIVE

Celiac artery (CA) incorporation during fenestrated-branched aortic aneurysm repair (FB-EVAR) for complex abdominal aortic aneurysms (cAAAs) is typically performed with fenestrations. Double-wide scallops (DWS) can be used when appropriate. We aimed to assess outcomes of patients treated with DWSs for the CA during FB-EVAR for cAAAs.

METHODS

This is a single-center retrospective review of patients enrolled in a prospective investigational device exemption trial undergoing FB-EVAR for cAAA from 2013 to 2020. The use of DWS or fenestrations for the management of the CA was selected to optimize seal. Patients with longer lengths of normal caliber aorta between the renal and celiac arteries, and without thoracic aortic ectasia or multifocal thoracic aortic aneurysms, were considered for DWS, whereas those with shorter visceral segment seal zones or thoracic aortic disease were preferentially treated with fenestrations for the CA. End points were morbidity, mortality, technical success, freedom from type IA endoleak, and target vessel instability (TVI).

RESULTS

FB-EVAR with CA DWS or fenestration was performed in 131 patients, including 97 males (74%). DWSs were used in 68 patients (52%) and fenestrations in 63 (48%). The mean patient age was 75.0 ± 7.4 years in both groups. Demographics, cardiovascular risk factors, and mean aortic diameter (P = .382) were similar between groups. The median number of incorporated vessels was similar (4; P = .373) between groups. The median endovascular operative time (DWS = 118 minutes [interquartilr range (IQR), 98-154 minutes]; fenestration = 141 minutes [122-170 minutes]; P = .006) and fluoroscopy time (DWS = 64 minutes [IQR, 51-78 minutes]; fenestration = 70 minutes [IQR, 61-83 minutes]; P = .032) were shorter with DWS, with no difference in contrast volume (P = .204). Technical success was 96% with DWS and 100% with fenestrations (P = .096). Three patients with DWS had partial or complete CA coverage. Median aortic coverage (above CA) was higher with fenestrations (fenestration = 5.5 cm [IQR, 4.5-6.4 cm]; DWS = 3.8 cm [IQR, 3.5-4.2 cm]; P < .001). There was no difference in 30-day mortality (DWS = 0%, fenestration = 1.6%; P = .297) or major adverse events (DWS = 17.6% vs fenestration = 17.5%; P = .978). The median follow-up was 42 months [Q1, Q3, 25, 50]. There were no type IA endoleaks, aortic ruptures, or open conversions. There was no difference in sac regression (DWS = 60%, fenestration = 67%; P = .449), survival (P = .859), or CA TVI (P = .320).

CONCLUSIONS

FB-EVAR with DWS and fenestrations show comparable perioperative and long-term outcomes without significant differences in technical success, TVI, or sac regression when used with precise device selection based on visceral segment seal zone lengths and risk for aortic degeneration. Device design should be determined by patient anatomy and seal zone given comparable outcomes.

Prevalence and clinical implications of the rare arc of Bühler using computed tomography angiography and digital subtraction angiography: a systematic review and meta-analysis

Background

Knowledge of the rare arc of Bühler (AOB) is limited but clinically important. At present, there is no publication of systematic review and meta-analysis on AOB in computed tomography angiography (CTA) and digital subtraction angiography (DSA) examinations.

Objective

The objective of this study was to evaluate the pooled prevalence and clinical implications of the AOB by using CTA and DSA examinations.

Methods

The PubMed, Web of Science, Scopus, Embase, Google Scholar, CBM, CNKI, WanFang, VIP, and Baidu Scholar databases were comprehensively searched for AOB-related literature. Stata 17.0 software was used to conduct the meta-analysis.

Results

Eleven publications with 3,837 patients and 65 AOB cases were included. The pooled prevalence of AOB was 1.9% (95% confidence interval: 0.8-3.2%). CTA showed a pooled prevalence of AOB of 2.0% (95% confidence interval: 0.5-4.3%) and DSA showed a pooled prevalence of AOB of 1.8% (95% confidence interval: 0.5-3.9%).

Conclusion

AOB is a rare anatomical variant, with a pooled prevalence of 1.9% in the general population. General surgeons, vascular surgeons, and interventional radiologists should consider its existence when performing relevant abdominal procedures to avoid intraoperative difficulties, visceral organ ischemia or bleeding, and other complications.

A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery

PURPOSE

In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL).

METHODS

Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done.

RESULTS

Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties.

CONCLUSION

This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

Important Variations of Aortic Branches: Imaging Case Series

Various anatomical variations are known to occur in branches of the aorta. Some of these variations are common while others are quite uncommon. However, these variations carry significant implications when the patient is diseased and some intervention or surgical procedure is to be done. Most of these variations are usually incidentally detected. This imaging case series illustrates some clinically important variations of aortic branches including branches of the aortic arch and abdominal aorta, with a review of the literature. All cases illustrated here were detected incidentally.

Diagnostic and Surgical Implications of Non-occlusive Mesenteric Ischemic Ileus Associated With Common Celiacomesenteric Trunk: A Case Report and Literature Review

The celiacomesenteric trunk (CMT), an exceedingly rare anatomic variant uniting the celiac artery and superior mesenteric artery (SMA), holds significant clinical and surgical implications. Despite its rarity, understanding these implications is crucial for effective management. This report outlines the case of a 99-year-old female presenting with septic shock and abdominal pain, with imaging revealing an incidental CMT. This paper aims to elucidate the surgical implications associated with CMT through a comprehensive case review and literature search. A 99-year-old female with multiple cardiovascular comorbidities presented with altered mental status and right lower quadrant abdominal pain. Upon arrival, the patient exhibited disorientation, an inability to follow commands, hypoxia, and hypotension. Significant laboratory findings included a white count of 20.6 x 109/L, lactate of 6.1 mmol/L, glucose of 53 mg/dL, alanine transaminase (ALT)/aspartate aminotransferase (AST) of 186/336 U/L, and creatinine of 4.2 mg/dL. Immediate interventions involved high-flow oxygen, fluid resuscitation, intravenous antibiotics, and admission to the ICU for septic shock. A CT angiogram (CTA) revealed an incidental large common trunk comprising the celiac trunk and superior mesenteric artery (SMA). There was a high-grade stenosis at the origin of the SMA. However, all the vessels were widely patent distally, and acute mesenteric occlusion was ruled out. By day 12, the patient achieved clinical stability after conservative management and was discharged. Complications such as aneurysm, dissection, stenosis, thrombosis, or acute occlusion of a CMT may necessitate complex surgical interventions, including endovascular procedures or open hepatic surgery. Understanding these technical complexities is vital for avoiding surgical complications in critically ill patients.

Use of selective visceral angiography in surgical strategy planning for celiac artery aneurysm in the celiacomesenteric trunk

BACKGROUND

The celiacomesenteric trunk (CMT) is a common duct of the celiac artery (CA) and the superior mesenteric artery originating from the aorta, which is an uncommon anatomical variant of visceral artery circulation. Because of the variety of visceral circulation in those with CMT, the visceral circulation associated with each branch should be evaluated prior to surgical treatment of visceral artery aneurysm in the CMT.

CASE PRESENTATION

A 64-year-old woman was diagnosed with a CA aneurysm in the CMT. Aneurysmectomy of the aneurysm was performed successfully. On preoperative selective visceral angiography, the CA was seen to bifurcate into the common hepatic and splenic artery. The left gastric artery was directly isolated from the aorta and perfused to the common hepatic and splenic artery through collateral circulation. These findings showed that celiac artery embolization is anatomically feasible, even in cases of celiac artery aneurysm rupture.

CONCLUSIONS

Selective visceral angiography can contribute to surgical strategy planning for CA aneurysm with CMT.

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

Acute occlusion of celiomesenteric trunk variants such as a replaced common hepatic artery origin from a superior mesenteric artery can be catastrophic and requires immediate attention to reverse simultaneous mesenteric and hepatic ischemia and prevent death. We report the case of a 73-year-old woman with acute occlusion of her celiomesenteric trunk and proximal superior mesenteric artery who underwent successful endovascular repair with stent graft via brachial access. In the present case report, we describe a surgically relevant classification system of celiomesenteric trunk variants, highlight the feasibility of endovascular intervention in this uncommon scenario, and describe our technique.

Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study

PURPOSE

Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL.

METHODS

Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors.

RESULTS

A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL.

CONCLUSION

Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.

Evaluation of celiac artery and common hepatic artery variations by CT-angiography and new classification model

PURPOSE

Knowledge of anatomical variations is important in all interventional procedures. This study aims to evaluate the variations and prevalence of celiac trunk (CeT) and its branches.

METHODS

The computerized tomography-angiography (CT-A) findings of 941 adult patients were evaluated retrospectively. Variations of the CeT and common hepatic artery (CHA) were evaluated according to the number of branches and their origin. Findings were compared with classical classification methods. A new classification model has been defined.

RESULTS

Normal (complete) trifurcation was detected in 856 (90.9%) of them, where left gastric artery (LGA), splenic artery (SpA) and CHA branches were derived from the CeT. Among 856 complete trifurcation cases, 773 (90.3%) had non-classical trifurcation patterns. The rate of classic trifurcation was 8.8%, while non-classic trifurcation was 82.1% in all cases. In one case (0.1%), LGA and left hepatic artery together and right hepatic artery and SpA together appeared as a double bifurcation. Complete celiacomesenteric trunk was observed only in 4 (0.42%) cases. In seven cases (0.7%), LGA, SpA and CHA were coming out of abdominal aorta (AAo) independently. CHA normal anatomy (Michels Type I) was detected in 618 (65.5%) patients. We found that 49 (5.2%) of our cases were ambiguous according to the Michels Classification. We have described five different variations of hepatic arteries directly arising from the AAo.

CONCLUSION

Preoperative recognition of anatomical variations of CeT, superior mesenteric artery and CHA is of primary importance in both surgical and radiological procedures. With careful evaluation of CT-angiographies, it is possible to detect rare variations.

A Comparison of the Celiacomesenteric Trunk in the Caribbean with Global Prevalence Calculated by a Systematic Review

Background

Typically, the celiac trunk and superior mesenteric artery branch off separately from the anterior aspect of the abdominal aorta. The celiacomesenteric trunk (CMT) is a rare variant in which those arteries share a common origin. We sought to compare the prevalence of CMT in the Caribbean with the global prevalence as calculated by a systematic review.

Methods

In this study, we evaluated all consecutive patients who had multiphase contrast-enhanced CT scans at two major referral centres in the Caribbean from August 30, 2017, to September 1, 2019. In patients with a CMT, we recorded demographic and anatomic details. We then conducted a systematic literature search and retrieved raw data to calculate the global prevalence (number of individuals with a CMT divided by the sum total of study samples). We compared CMT prevalence in our sample with the global prevalence using Pearson's chi-square and Fisher's exact tests. Statistical significance was considered to be present when the P value was <0.05.

Results

From 832 CTs, 665 scans met the inclusion criteria. There were 16 (2.41%) CMTs: 3 (0.45%) classic CMTs, 12 (1.8%) hepato-mesenteric trunks, and 1 (0.15%) hepato-spleno-mesenteric trunk. Forty-two studies reported on CMTs in a total of 74,320 persons. The global CMT prevalence was comparable (3.88%; P = 0.054), but the incidence of hepato-mesenteric variants was significantly lower in our sample (1.8% vs. 3.24%; P = 0.0352).

Conclusion

There was no difference in the prevalence of a classic CMT in the Caribbean compared to the global prevalence. However, the hepato-mesenteric trunk (incomplete CMT variant) was significantly less prevalent in the Caribbean. Advances in Knowledge: Healthcare professionals performing hepatobiliary interventions must be aware of these differences in order to minimize morbidity during their interventions.

Intestinal ischemia in a patient with vascular malformation: a recipe for disaster

Anatomical variations of the celiac and mesenteric artery have been described over the past two centuries; many of these variations will have no clinical repercussions and will only be found incidentally or during imaging studies. However, these variations can lead to severe complications if undetected during surgery, transplantation or when they are affected by ischemia. Therefore, prompt treatment is needed to overcome these dangerous scenarios. We present the case of a 71-year-old patient who had a celiacomesenteric trunk and developed transient intestinal ischemia; however, he suffered severe acidosis and hyperlactatemia that ultimately led to organ failure and death.

A Hepatogastrophrenic Trunk, Celiacomesenteric Trunk, and a Middle Mesenteric Artery in a 68-Year-Old White Male Donor

A detailed understanding of the enteric vascular supply is of great importance for pre-operative planning. In the case of this 68-year-old white male donor, the following variations were observed: a hepatogastrophrenic trunk, a celiacomesenteric trunk, and a middle mesenteric artery. Literature review was conducted to understand the frequency and clinical significance of these variations.

Unraveling Variations in Celiac Trunk and Hepatic Artery by CT Angiography to Aid in Surgeries of Upper Abdominal Region

Understanding of variations in the course and source of abdominal arteries is crucial for any surgical intervention in the peritoneal space. Intricate surgeries of the upper abdominal region, such as hepato-biliary, pancreatic, gastric and splenic surgeries, require precise knowledge of regular anatomy and different variations related to celiac trunk and hepatic artery. In addition, information about the origin of inferior phrenic artery is important in conditions such as hepatocellular carcinoma and gastroesophageal bleeding management. The present study gives an account of anatomical variations in origin and branching pattern of celiac trunk and hepatic artery by the use of CT (computed tomographic) angiography. The study was performed on 110 (66 females and 44 males) patients in a north Indian population. Results unraveled the most common celiac trunk variation as hepatosplenic trunk with left gastric artery, which was observed in 60% of cases, more common in females than in males. Gastrosplenic and hepato-gastric trunk could be seen in 4.55% and 1.82% cases respectively. Gastrosplenic trunk was more commonly found in females, whereas hepato-gastric trunk was more common in males. A gastrosplenic trunk, along with the hepato-mesenteric trunk, was observed in 1.82% cases and was more common in males. A celiacomesenteric trunk, in which the celiac trunk and superior mesenteric artery originated as a common trunk from the aorta, was seen only in 0.91% of cases, and exhibited an origin of right and left inferior phrenic artery from the left gastric artery. The most common variation of hepatic artery, in which the right hepatic artery was replaced and originated from the superior mesenteric artery, was observed in 3.64%, cases with a more common occurrence in males. In 1.82% cases, the left hepatic artery was replaced and originated from the left gastric artery, which was observed only in females. Common hepatic artery originated from the superior mesenteric artery, as observed in 1.82% cases, with slightly higher occurrence in males. These findings not only add to the existing knowledge apart from giving an overview of variations in north Indian population, but also give an account of their correlation with gender. The present study will prove to be important for various surgeries of the upper abdominal region.

A new classification and strategies for endovascular treatment of celiac artery aneurysms

BACKGROUND

Endovascular treatment is being increasingly used for celiac artery aneurysms (CAAs), but systematic endovascular treatment strategies have not been defined yet. This study intended to investigate the strategies of endovascular management of CAAs according to a single-center experience.

METHODS

Anatomically, CAAs were classified into two types: Type I CAAs located in the main trunk of celiac artery. Type II CAAs located on the branches of the celiac artery. Type I and Type II CAAs can be further divided into two different subtypes according to fusiform (a) or saccular or (b) morphology: type Ia, type Ib, type IIa, and type IIb. Patient demographics, clinical manifestations, aneurysm characteristics, endovascular intervention procedures, and perioperative and follow-up outcomes were reviewed and analyzed.

RESULTS

Between August 2012 and August 2020, 18 consecutive patients (12 men; mean age, 56.8 ± 14.5 years) with CAAs were identified and treated with endovascular procedures. There were seven patients with type Ia, three patients with type Ib, four patients with type IIa, and four patients with type IIb CAAs. One patient died of hemorrhagic shock due to a ruptured aneurysm. Technical success was achieved in 16 patients (88.9%). The mean follow-up period was 51.7 ± 19.4 months. No hepatic or intestinal ischemia or death developed perioperatively or during the follow-up period. No aneurysmal expansion was detected on CTA surveillance, except for one patient who was diagnosed with an endoleak during the follow-up and received reintervention.

CONCLUSIONS

The endovascular strategy based on the novel classification of CAAs was safe and effective, with a favorable mid-term clinical outcome.

Subacute duodenal obstruction caused by Common Celiaco-Mesenteric Trunk anomaly-A case report

Introduction and importance

The origin of the mesenteric vasculature is highly variable. One such variation is the common celiaco-mesenteric trunk (CMT). To our knowledge, this is the first reported case of subacute duodenal obstruction caused by common CMT. The awareness of this anomaly helps keep a high index of suspicion for varied presentations, prompts appropriate investigations, timely intervention, and avoids iatrogenic injury.

Patient profile

A 15-year-old boy presented with a history of repeated attacks of colicky abdominal pain with bilious vomiting. Computed tomography of the abdomen with intravenous contrast revealed subacute duodenal obstruction caused by an acute angulation of common CMT with the abdominal aorta. To relieve the obstruction, the patient underwent a side-to-side duodenojejunostomy.

Discussion

A common CMT, where the coeliac artery (CA) and superior mesenteric artery (SMA) have a common origin from the aorta, accounts for less than 1% of all splanchnic artery anomalies. Most CMTs are incidental findings, but aneurysm or dissection of the common trunk commonly accompany this anatomical aberrancy. Intestinal obstruction due to CMT anomaly is a rare occurrence.

Conclusion

There should be a high index of suspicion concerning vascular anomalies in patients, especially children presenting with repeated episodes of subacute intestinal obstruction. This knowledge of vascular aberrations prevents disastrous iatrogenic complications.

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Rarity of the occurrence of common celiacomesenteric trunk

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As per our knowledge this is the first reported case of CMT presenting with duodenal obstruction.

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Its similarity to Wilkie's syndrome in terms of patient and management

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Different presentations of CMT

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Knowledge of this variations important in other surgeries and endovascular procedures to avoid dreadful complications.