Presentation
Vague chronic upper abdominal pain for years. Often worse after eating.
Patient Data
Upper abdominal solid organs are unremarkable.
Midline sagittal images show focal smooth narrowing of the proximal celiac artery. Features suggest external compression.
There is also prominent vessels seen in the pancreas head region suggesting collateral flow.
Initial aortogram confirms smooth stenosis of the proximal coeiliac artery.
Selective superior mesenteric artery injection demonstrates a replaced right hepatic artery. There is however also filling of the left hepatic artery via the pancreatico-duodenal arcade. Retrograde flow is also observed into the common hepatic artery with filling of the splenic artery and celiac on the late images.
Selective injection of the celiac artery during inspiration again shows the tight smooth stenosis well. This injection is repeated during expiration where complete occlusion is seen with no flow into the distal portion of the celiac artery.
Case Discussion
This patient had a chronic history of vague upper abdominal symptoms.
Initial CT had the unexpected finding of celiac artery stenosis. There is smooth stenosis with the appearance of external compression. CT findings were compatible with median arcuate ligament syndrome, where the median arcuate ligament compresses the proximal celiac artery (also known as Dunbar syndrome). This characteristic appearance of the celiac artery compression may, however, be seen in normal subjects, especially when imaged during expiration. CT, however, had some secondary signs supporting the diagnosis including post stenotic dilatation and suspected pancreatico-duodenal collaterals.
The patient then underwent conventional angiography. Selective celiac injections were done in both inspiration and expiration. During inspiration, the appearance was similar to the CT with smooth, fairly tight stenosis and post stenotic dilatation. During expiration, there was however no flow through the stenosis which was completely compressed. This together with the retrograde filling of the celiac branches, when injecting the superior mesenteric artery confirmed the significance of the compression in the patient. Angiography findings further supported the diagnosis of Median Arcuate Ligament Syndrome.
The patient underwent surgery 2 days later to decompress the celiac artery.