Download Celiac trunk: anatomical variants and pathological findings at MDCT

Celiac trunk: anatomical variants and pathological findings
at MDCT
Poster No.:
C-2375
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
L. Silva , J. Brito , C. N. Tentugal , M. O. E. Castro , L. Curvo-
1
1
2
1
1 1
1
2
Semedo , F. Aleixo ; Portimão/PT, Coimbra/PT
Keywords:
Arteriovenous malformations, Aneurysms, Normal variants, CTAngiography, Arteries / Aorta, Anatomy, Abdomen
DOI:
10.1594/ecr2013/C-2375
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Page 1 of 43
Learning objectives
To review the anatomical variants and pathological findings affecting the celiac trunk, as
observed on multidetector computed tomography (MDCT), such as stenosis, occlusion,
vasculitis, compression by the median arcuate ligament, tumor invasion, aneurysm,
dissection, arteriovenous malformation, and pulmonary sequestration.
Background
The celiac trunk is the first branch that originates from the abdominal aorta just below
the diaphragm and divides into the left gastric artery, the common hepatic artery and the
splenic artery, as first observed by Haller (Fig. 1 on page 4).
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Fig. 1: VRT image created from CT angiography data showing the normal anatomy
of the celiac trunk, as first observed by Haller. The celiac trunk divides into the splenic
artery (thick white arrow), the left gastric artery (curved arrow) and the common hepatic
artery (arrowhead), which originates the gastroduodenal artery (open white arrow) and
the proper hepatic artery. The latter divides into the left hepatic artery (thin long arrow)
and the right hepatic artery (thin short arrow).
References: Radiologia, Centro Hospitalar do Barlavento Algarvio - Portimão/PT
Celiac trunk anatomical variants, first classified by Adachi in 1928, are not infrequent
(15% of the human population) and knowledge of the existing aberrations is becoming
mandatory in planning and conducting surgical or interventional procedures.
Nowadays, MDCT angiography has become a valuable minimally invasive tool for
the visualization of normal vascular anatomy and its variants, as well as pathological
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conditions of the celiac trunk and its vessels. Furthermore, the use of advanced postprocessing techniques, which take advantage of near-isotropic imaging, multiplanar
reformation (MPR), maximum intensity projection (MIP) and 3-dimensional volume
rendering techniques (VRT) can help to confidently diagnose these entities, assist in
planning further management, particularly endovascular intervention, and significantly
reduce the procedure time and overall radiation dose to the patient.
Images for this section:
Fig. 1: VRT image created from CT angiography data showing the normal anatomy of
the celiac trunk, as first observed by Haller. The celiac trunk divides into the splenic
artery (thick white arrow), the left gastric artery (curved arrow) and the common hepatic
artery (arrowhead), which originates the gastroduodenal artery (open white arrow) and
Page 4 of 43
the proper hepatic artery. The latter divides into the left hepatic artery (thin long arrow)
and the right hepatic artery (thin short arrow).
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Imaging findings OR Procedure details
Anatomical variants
Anatomical variants of the celiac trunk were first classified by Adachi in 1928, based on
252 dissections of Japanese cadavers, where six types of divisions of the celiac trunk and
superior mesenteric artery were described. In 1955, Michel created another classification,
also including six types of divisions, and according to which, the most common variant is
a replaced right hepatic artery originating from the superior mesenteric artery (Fig. 2 on
page 17). Since then, there have been published several other papers with different
classifications. On a recent paper by Song et al, up to 15 types of celiac axis anatomy,
including normal celiac trunk, are theoretically possible.
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Fig. 2: VRT image created from CT angiography data showing the right hepatic artery
(arrowhead) originating from the superior mesenteric artery (thick white arrow). Note
the celiac trunk trifurcating into left gastric artery (open black arrow), splenic artery
(curved arrow) and common hepatic artery. The common hepatic artery bifurcates into
left hepatic artery (open white arrow) and gastroduodenal artery (thin long arrow).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
MDCT angiography has a reported accuracy of 97% to 98% compared with conventional
angiography for the detection of arterial variants (Fig. 3 on page 18, Fig. 4 on page
19, Fig. 5 on page 20, Fig. 6 on page 21, Fig. 7 on page 22, Fig. 8 on page
23, Fig. 9 on page 24, Fig. 10 on page 25, Fig. 11 on page 26, Fig. 12 on
page 27, Fig. 13 on page 28, Fig. 14 on page 29). The preoperative knowledge
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of these variants has tremendous surgical significance when laparoscopic procedures or
liver surgery are planned due to limited vision of the surgical field (Fig. 15 on page 30).
Moreover, recognition of the aberrant vessels can also be useful in transcatheter arterial
chemoembolisation and radioembolisation.
Fig. 15: Axial CT scan before (a) and after (b) administration of intravenous contrast
(late arterial phase). a. Hypodense round liver lesion (thick white arrow), near the
hilum. b. During the late arterial phase, this lesion has high attenuation, similar to the
arterial vessels. In fact, this lesion corresponds to an iatrogenic pseudoaneurysm of the
left hepatic artery, which has its origin on the left gastric artery. This patient had been
submited to surgery; the surgeons, unaware of this anatomical variant, injured the left
hepatic artery, leading to the creation of this pseudoaneurysm.
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Celiac trunk stenosis and occlusion
The suggested causes of celiac trunk stenosis are atherosclerosis (the most common
cause in Western populations), acute and chronic dissection, embolisation of intracardiac
thrombi in atrial fibrillation, coagulation disorders, external arterial compression by the
median arcuate ligament or neoformations, vasculitis, or as complication of procedures
such as Nissen fundoplication and chemoembolisation.
Bron and Redman reported an incidence of 12.5% among 713 patients referred for
abdominal aortography. In a series of 110 unselected cadavers by Derrick et al, the lumen
of the celiac trunk was narrowed by over 50% in 21% of cases. A high prevalence of
significant stenosis of the celiac artery has also been reported in asymptomatic patients.
However, clinically significant ischemic bowel disease secondary to celiac trunk stenosis
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(or occlusion) is rarely encountered, mainly owing to the development of rich collateral
vessels from the superior mesenteric artery, most commonly the pancreaticoduodenal
artery and the dorsal pancreatic artery (Fig. 16 on page 31, Fig. 17 on page 32,
Fig. 18 on page 33, Fig. 19 on page 34).
Fig. 16: VRT image created from CT angiography data showing a celiac trunk
stenosis (thick white arrow), with a pronounced dilation of the vessels of the
pancreaticoduodenal arcade (arrowhead). Note the associated small aneurysm of the
right hepatic artery (curved arrow).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Page 9 of 43
Median arcuate ligament syndrome
The median arcuate ligament is a fibrous band that connects the left and right
diaphragmatic crura across the aortic hiatus at the level of the T12/L1 vertebral bodies,
usually superior to the origin of the celiac axis. However, in 10% to 24% of people
the ligament may be low and therefore cross over the proximal portion of the celiac
artery; in some of these individuals, the ligament may actually compress the celiac trunk,
compromising blood flow and causing symptoms.
The relative position of the celiac trunk and the median arcuate ligament varies
with respiration, with celiac compression being significantly lower and minimal at end
inspiration and maximal at end expiration.
The diagnosis of clinically significant median arcuate ligament syndrome can be
diagnosed with three-dimensional CT angiography, which demonstrates a characteristic
focal narrowing in the proximal celiac axis. This focal narrowing has a characteristic
hooked appearance, which can help distinguish this condition from other causes of celiac
trunk narrowing, such as atherosclerotic disease.
CT is typically performed during inspiration; therefore, if the focal narrowing is observed
during inspiratory CT, it may be clinically significant. Also, associated poststenotic
dilatation or collateral vessels may suggest actual pathologic conditions and warrant
clinical correlation (Fig. 20 on page 35).
Fig. 20: MIP (a) and VRT (b, c) images created from CT angiography data showing
the characteristic hooked appearence (a, b, thick white arrows) of the focal narrowing
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of the celiac trunk caused by the median arcuate ligament, and the dilated collateral
vessels from the pancreaticoduodenal arcade (c, arrowheads).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Celiac trunk aneurysm
Celiac trunk aneurysms are extremely rare and account for less than 4% of all splanchnic
aneurysms (Fig. 9 on page 24, Fig. 21 on page 36). These aneurysms are often
degenerative, reportedly being associated with aortic aneurysms in 20% of cases and
with other visceral artery aneurysms in 40%.
Fig. 21: VRT images created from CT angiography data showing a celiac trunk
aneurysm (thick white arrows).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Due to the rarity of these aneurysms their natural history remains unclear. The
detection of such aneurysms, which are often asymptomatic, is mostly incidental during
diagnostic imaging for other reasons. When symptomatic, they may present as abdominal
discomfort localized to the epigastrium (60% of cases) and/or a pulsatile abdominal mass
(30% of cases) and be easily detected on angiographic MDCT.
The most serious complication of celiac trunk aneurysms is rupture. The recent
assessment of the risk of rupture as being 13% with mortality rates approaching 100%
has led to their aggressive surgical management.
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Aneurysms may also arise on the branches of the celiac trunk. Among these, the
hepatic artery aneurysm is the most common (the second most common visceral artery
aneurysm), even more than celiac trunk aneurysms (Fig. 16 on page 31).
Celiac trunk dissection
Arterial dissection is defined as cleavage of the arterial wall by an intramural hematoma
between two elastic layers. Isolated spontaneous dissection of the celiac trunk is rare
(most commonly associated with aortic dissection) and historically has afforded a poor
prognosis. The natural history is unpredictable, but spontaneous resolution, definitive
occlusion of a visceral artery, aneurysm formation, or rupture can occur.
CT angiography is considered the primary technique for diagnosing celiac trunk
dissection. Diagnostic imaging findings on CT include an intimal flap, which is
pathognomonic, or eccentric mural thrombus in the celiac lumen, which should raise
suspicion for dissection (Fig. 22 on page 36, Fig. 23 on page 37). As a secondary
sign, there may be found infiltration of the fat surrounding the celiac axis.
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Fig. 22: Axial CT scan during arterial phase showing an intimal flap in the aorta (thick
white arrow), which indicates aortic dissection, extending to the celiac trunk (open
white arrow).
References: L. Curvo-Semedo, Radiology Department, CHUC, Coimbra, Portugal
Page 13 of 43
Fig. 23: Axial CT scan during arterial phase showing an intimal flap in the aorta (thick
white arrow), which indicates aortic dissection. In this case, there is also an eccentric
mural thrombus (arrowhead). The intimal flap prolongs into the celiac trunk (open white
arrow).
References: L. Curvo-Semedo, Radiology Department, CHUC, Coimbra, Portugal
Arteriovenous malformation
Arteriovenous malformation is a congenital lesion where persistent abnormal connection
is observed between veins and arteries originating from an embryonic failure in the
vascular development of the affected region.
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From the celiac branches, the most commonly affected vessel is the common hepatic
artery, in the form of arterioportal shunts. This type of communication between the hepatic
artery and the portal vein may result in portal hypertension.
Contrast-enhanced CT usually shows the tortuous vascular structure with arterial
enhancement connecting both vessels, giving rise to early enhancement of the main
portal vein (Fig. 24 on page 38).
Fig. 24: MIP (a) and VRT (b) images created from CT angiography data showing
extrahepatic arteriovenous malformation (thick white arrows) between the common
hepatic artery (arrowheads) and the portal vein (open white arrows), with early
enhancement of the latter. Note that this patient also has an intrahepatic portosystemic
shunt (a, curved arrow).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Pulmonary sequestration and pseudosequestration
Pulmonary sequestration is defined as an aberrant lung tissue mass that has no normal
connection with the bronchial tree or with the pulmonary arteries. The arterial blood supply
arises from the systemic arteries, usually the thoracic or abdominal aorta, and its venous
drainage is via the azygos and hemiazygos system, the pulmonary veins, or the inferior
vena cava. Sequestration is divided into two types: extralobar and intrapulmonary (most
common), according to the presence or absence of its own separate pleura.
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CT angiography can easily depict this condition and the origin of its nurturing vessel (Fig.
25 on page 39).
Fig. 25: Axial CT scan images of the thorax, in pulmonary (a) and mediastinal (b-g)
windows, after injection of intravenous contrast, during the arterial phase, showing
abnormal lung tissue mass (a, thick white arrow), which is nurtured by a vessel (b-f,
arrowheads) originating from the celiac trunk (g, open white arrow).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
Pseudosequestration involves the combination of systemic arterial supply to the lungs
with normal bronchial connections and coexistent infection. It is presumed that chronically
inflamed lung tissue may activate neovascularization from systemic circulation (Fig. 26
on page 39).
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Fig. 26: Axial CT scan images of the thorax, in pulmonary (a) and mediastinal (b, d)
windows, after injection of intravenous contrast, during the arterial phase and MIP (c)
images showing abnormal area of the right lower lobe with bronchiectasis (a, thick
white arrow), which is supplied by dilated infradiaphragmatic arteries (b-d, open white
arrow) with origin on the celiac trunk (d, arrowhead).
References: J. Brito, Radiology Department, CHBA, Portimão, Portugal
It may be difficult to distinguish pulmonary sequestration from pseudosequestration. At
angiographic MDCT, sequestrations generally demonstrate a clearly anomalous vessel
supplying the mass, whereas small branches of hypertrophied normal vessels supply
pseudosequestrations, which are prominent on the surface of the mass. Pulmonary
sequestrations should not be associated with a pleural blush, which is a clue to the
diagnosis of pseudosequestration. In addition, a sequestration should demonstrate
enhancement with contrast material at CT, whereas a pseudosequestration enhances
only at the periphery of the lesion, if at all.
Images for this section:
Page 17 of 43
Fig. 2: VRT image created from CT angiography data showing the right hepatic artery
(arrowhead) originating from the superior mesenteric artery (thick white arrow). Note the
celiac trunk trifurcating into left gastric artery (open black arrow), splenic artery (curved
arrow) and common hepatic artery. The common hepatic artery bifurcates into left hepatic
artery (open white arrow) and gastroduodenal artery (thin long arrow).
Page 18 of 43
Fig. 3: VRT image created from CT angiography data showing the common hepatic artery
(arrowhead) originating from the superior mesenteric artery (thick white arrow). Note that
the common hepatic artery bifurcates into gastroduodenal artery (thin long arrow) and
proper hepatic artery. The latter bifurcates into left hepatic artery (open white arrow) and
right hepatic artery (curved arrow). The splenic artery (black arrow) originates from the
celiac trunk.
Page 19 of 43
Fig. 4: MIP image created from CT angiography data showing splenic artery (curved
arrow) and left gastric artery (thick white arrow) with independent origins from the aorta.
The common hepatic artery (arrowhead) has its origin from the superior mesenteric artery
(open white arrow).
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Fig. 5: VRT image created from CT angiography data showing the left hepatic artery
(curved arrow) originating from the left gastric artery (thick white arrow).
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Fig. 6: VRT image created from CT angiography data showing the left hepatic
artery (curved arrow) originating on the left gastric artery (thick white arrow) and the
gastroduodenal artery (arrowhead) originating directly from the celiac trunk.
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Fig. 7: VRT image created from CT angiography data showing the left hepatic artery
(curved arrow) and the right hepatic artery (arrowhead) originating directly from the celiac
trunk, thus the common hepatic artery is nonexistent. Note that the gastroduodenal artery
(thick white arrow) originates from the left hepatic artery. Horseshoe kidney is a casual
finding.
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Fig. 8: VRT image created from CT angiography data showing independent origin from
the aorta of the left gastric artery (curved arrow), common hepatic artery (arrowhead) and
splenic artery (thick white arrow), thus the celiac trunk is nonexistent.
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Fig. 9: VRT image created from CT angiography data showing left gastric artery (thick
white arrow) with an independent origin from the aorta. Note the aneurysm of the celiac
trunk (arrowhead).
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Fig. 10: VRT image created from CT angiography data showing quadrifurcation of the
celiac trunk into left gastric artery (curved arrow), splenic artery (thick white arrow),
common hepatic artery (arrowhead) and gastroduodenal artery (open white arrow). Note
that the left hepatic artery (thin white arrow) originates from the left gastric artery.
Page 26 of 43
Fig. 11: VRT images created from CT angiography data showing 2 examples of triple
hepatic artery - left, middle and right. Note that in all the examples the left hepatic artery
(thick white arrow) originates from the left gastric artery (curved arrow) and the right
hepatic artery (arrowhead) originates from the superior mesenteric artery (open white
arrow). The middle hepatic artery (thin long arrow) has different origins: a) from the
celiac trunk along with the gastroduodenal artery (open arrowhead); b) from the superior
mesenteric artery along with the right hepatic artery.
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Fig. 12: VRT image created from CT angiography data showing right hepatic artery
(thick white arrow) originating from the splenic artery (curved arrow). Note that the left
hepatic artery (arrowhead) originates from the left gastric artery (open white arrow) and
the gastroduodenal artery (thin long arrow) originates from the right hepatic artery.
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Fig. 13: VRT image created from CT angiography data showing common hepatic artery
(thick white arrow) originating directly from the aorta. The splenic artery (arrowhead) and
the left gastric artery (curved arrow) originate from the celiac trunk.
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Fig. 14: VRT image created from CT angiography data showing left hepatic artery (thick
white arrow) arising from the common hepatic artery (open white arrow). The common
hepatic artery later divides into the gastroduodenal artery (curved arrow) and the right
hepatic artery (arrowhead).
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Fig. 15: Axial CT scan before (a) and after (b) administration of intravenous contrast
(late arterial phase). a. Hypodense round liver lesion (thick white arrow), near the hilum.
b. During the late arterial phase, this lesion has high attenuation, similar to the arterial
vessels. In fact, this lesion corresponds to an iatrogenic pseudoaneurysm of the left
hepatic artery, which has its origin on the left gastric artery. This patient had been
submited to surgery; the surgeons, unaware of this anatomical variant, injured the left
hepatic artery, leading to the creation of this pseudoaneurysm.
Page 31 of 43
Fig. 16: VRT image created from CT angiography data showing a celiac trunk stenosis
(thick white arrow), with a pronounced dilation of the vessels of the pancreaticoduodenal
arcade (arrowhead). Note the associated small aneurysm of the right hepatic artery
(curved arrow).
Page 32 of 43
Fig. 17: VRT images created from CT angiography data showing stenosis of the celiac
trunk (a, thick white arrow), superior mesenteric artery (a, arrowhead) and the renal
arteries (b, curved arrows), in a patient with vasculitis.
Page 33 of 43
Fig. 18: Contrast-enhanced axial CT image showing vascular encasement of the celiac
trunk (thick white arrow) by pancreatic adenocarcinoma. There is pancreatic parenchyma
atrophy in the tail, a biliary prosthesis and a small amount of intraperitoneal fluid.
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Fig. 19: VRT image created from CT angiography data showing common hepatic artery
occlusion (thick white arrow). The liver still has arterial blood supply due to the collateral
vessels from the superior mesenteric artery (arrowheads).
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Fig. 20: MIP (a) and VRT (b, c) images created from CT angiography data showing the
characteristic hooked appearence (a, b, thick white arrows) of the focal narrowing of the
celiac trunk caused by the median arcuate ligament, and the dilated collateral vessels
from the pancreaticoduodenal arcade (c, arrowheads).
Fig. 21: VRT images created from CT angiography data showing a celiac trunk aneurysm
(thick white arrows).
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Fig. 22: Axial CT scan during arterial phase showing an intimal flap in the aorta (thick
white arrow), which indicates aortic dissection, extending to the celiac trunk (open white
arrow).
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Fig. 23: Axial CT scan during arterial phase showing an intimal flap in the aorta (thick
white arrow), which indicates aortic dissection. In this case, there is also an eccentric
mural thrombus (arrowhead). The intimal flap prolongs into the celiac trunk (open white
arrow).
Page 38 of 43
Fig. 24: MIP (a) and VRT (b) images created from CT angiography data showing
extrahepatic arteriovenous malformation (thick white arrows) between the common
hepatic artery (arrowheads) and the portal vein (open white arrows), with early
enhancement of the latter. Note that this patient also has an intrahepatic portosystemic
shunt (a, curved arrow).
Fig. 25: Axial CT scan images of the thorax, in pulmonary (a) and mediastinal (bg) windows, after injection of intravenous contrast, during the arterial phase, showing
abnormal lung tissue mass (a, thick white arrow), which is nurtured by a vessel (b-f,
arrowheads) originating from the celiac trunk (g, open white arrow).
Page 39 of 43
Fig. 26: Axial CT scan images of the thorax, in pulmonary (a) and mediastinal (b, d)
windows, after injection of intravenous contrast, during the arterial phase and MIP (c)
images showing abnormal area of the right lower lobe with bronchiectasis (a, thick white
arrow), which is supplied by dilated infradiaphragmatic arteries (b-d, open white arrow)
with origin on the celiac trunk (d, arrowhead).
Page 40 of 43
Conclusion
MDCT is able to provide high quality images of the celiac trunk, allowing prompt
recognition of anatomical variants, which should be reported, mainly in patients
undergoing surgical and/or angiographic procedures.
Moreover, patients with suspected vascular disease can easily be evaluated with MDCT.
A good understanding of the arterial architecture of this region prevents surgical and
angiographic mistakes that can occasionally become catastrophic.
References
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Personal Information
Luís Duarte Silva, MD* ([email protected])
Jorge Brito, MD*
Cláudia Tentúgal, MD*
Miguel Oliveira e Castro, MD*
Luís Curvo-Semedo, PhD**
Francisco Aleixo, MD*
*Department of Radiology, Centro Hospitalar do Barlavento Algarvio, Portimão, Portugal
**Department of Radiology, Centro Hospitalar Universitário de Coimbra, Coimbra,
Portugal
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