| Abstract|| |
Celiac artery aneurysms (CAAs) account for 4% of all visceral arteries aneurysms. They are rare, vascular lesions, usually asymptomatic and recognized coincidentally while searching for causes of abdominal pain or other intra abdominal problems. Their significance is in their potential to rupture, which can lead to death. CAAs have no gender predilection, with most manifesting during the fifth decade of life. The diagnosis of these rare aneurysms is being established more frequently as our use of cross-sectional imaging increases. We present the case of isolated celiac artery aneurysm diagnosed incidentally by routine ultrasonography (USG) of abdomen for lower abdominal pain, followed by three dimensional CT angiography of abdomen in a 65-year-old female.
Keywords: Aneurysm, celiac artery, color Doppler ultrasonography, computed tomography,
|How to cite this article:|
Sutariya HC, Patel KN, Gandhi SP. Isolated celiac artery aneurysm: A case report. Ann Trop Med Public Health 2017;10:247-50
| Introduction|| |
Celiac artery aneurysm (CAA) represents a rare form of aneurismal disease that accounts for 4% of all splanchnic aneurysms. Since the anomaly was first described in 1745, fewer cases have been reported in the internal medical literature. Approximately, 20% of patients will have an associated aneurysm and 38% will have a second splanchnic artery aneurysm. Although rare, they carry a definite risk for rupture and/or other complications. The reported risk for rupture varies in the literature, but appears to range from 10 to 20%. The exact presentation depends on the degree of involvement of the branched vessels of the celiac artery. Catheter angiography has been the traditional means of diagnosis. However, color Doppler sonography and three-dimensional imaging with multi detected computed tomography (MDCT), which permits visualization of the aorta and its branches, may detect aneurysms with greater frequency in symptomatic and asymptomatic patients. Multislice tomography images are provided along with a brief discussion on clinical presentations, diagnostic tools and treatment options in a case of isolated celiac artery aneurysm.
| Case Report|| |
A 65-year- old female was referred for ultrasonography (USG) in our radiology department for lower abdominal pain. There was no history of abdominal trauma. Her medical and family history was unremarkable. On physical examination, the patient appeared healthy and not in distress, without palpable mass or tenderness. Her vital signs were stable and peripheral pulses were normal. Comorbid conditions included hypertension and obesity. Her routine blood investigations, including liver enzymes and renal function tests, serum amylase and lipase levels, C-reactive protein and erythrocyte sedimentation rate were within normal limits. Her connective tissue disease workup, including antinuclear antibodies, was negative. Echocardiography showed normal valvular and myocardial functions. No history of diabetes or peripheral vascular disease was found. The USG of abdomen revealed hypoechoic mass of size 15×15 mm at the expected location of celiac trunk. Color Doppler imaging revealed turbulent and complex flow, confirming the presence of aneurysm. To know its exact extent and involvement of other vessels, triphasic contrast enhanced computed tomography (CT) of abdomen was performed on a somaton sensation 64 slice scanner of siemens machine using 100 mL of nonionic iodinated contrast material 350 mg/mL, injected at a rate of 3.5 mL/s. Arterial phase images of abdomen were obtained using bolus tracking technique, followed by portal and venous phase acquisition of the whole abdomen at 40 and 60s, respectively, from the start of contrast injection. The CT study revealed contrast filled out pouching from celiac artery measuring about 14×12 mm in size, approximately 13 mm from its origin-suggested aneurysm [Figure 1]. It also revealed that all its three branches—left gastric artery, splenic artery and main hepatic artery originated from aneurysmal dilatation [Figure 2]. No evidence of thrombosis or dissection within it was noticed. All other arteries like abdominal aorta, superior mesenteric artery, inferior mesenteric artery and renal arteries appear normal. No evidence of stenosis, thrombosis or aneurysm was noted.
|Figure 1: Thick Maximum intensity projection (MIP) axial image of computed tomographic angiography show celiac artery at origin (arrow), aneurysmal dilatation of celiac trunk (thick arrow), splenic artery (oval arrow) and common hepatic artery (diamond arrow) arising from aneurysm|
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|Figure 2: Volume-rendered (VR) coronal image of computed tomographic angiography of celiac artery shows about 14×12 mm sized aneurysm (thick arrow) involving celiac artery (arrow). Splenic artery (oval arrow), left gastric artery (open arrow), and common hepatic artery (diamond arrow) arising from it|
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Regarding the age of the patient, asymptomatic nature of aneurysm and absence of risk factors, the patient is managed conservatively. Follow up examination of the patient showed no evidence of increase in size of aneurysm in past 12 months.
| Discussion|| |
CAA is a rare type of splanchnic artery aneurysm that causes a high risk of mortality if they rupture. The estimated incidence of CAA ranges from 0.005 to 0.01%. It typically occurs in the sixth decade of life. The common risk factors include hypertension, atherosclerosis, abdominal aortic aneurysm; however, other causes include infection, tuberculosis or syphilis, trauma, pregnancy, cystic medial necrosis, fibromuscular dysplasia, polyarteritis nodosa and connective tissue disorders. They are usually asymptomatic and found incidentally. Otherwise they may present with especially abdominal pain, nausea, vomiting and as a pulsatile mass or abdominal bruit. Some Aneurysm are not discovered until they complicate with rupture. For patients who present with rupture, the aneurysm may rupture into the peritoneal cavity, retroperitoneum or thorax. Intraperitoneal rupture may initially be contained within the lesser sac, with subsequent free rupture into the peritoneal cavity, which produces the classic “double rupture” phenomenon. The rupture of CAA into the gastrointestinal tract presents with hematemesis and bright red blood from the rectum. Unusual presentations of CAA include extrinsic compression of the pancreatic duct, palpable mass, bleeding gastric varices as a result of splenic vein compression and hepatic and portal obstruction as a result of extrinsic compression. There have also been reports of CAA dissection with resulting end-organ infarction.
Over the past few decades, the incidence of rupture has decreased secondary to the increased use of ultrasound and MDCT. The USG imaging is well suited to detect CAA because of excellent acoustic access and insonating angle usually achieved in a supine or decubitus position. Aneurysms have complex flow dynamics, with high velocity jets centrally, reverse flow component, and near absence of flow near wall. In our case, the vascular nature of lesion was easily demonstrated by its direct continuity with the celiac trunk and color Doppler imaging revealed complex turbulent flow. MDCT permits visualization of the aorta, and its branches may detect aneurysms with greater frequency in symptomatic and asymptomatic patients., It is known that, on unenhanced MDCT, aneurysm can simulate a hypodense mass in peripancreatic region; thrombotic or hemorrhagic material in the aneurysm sac provides heterogeneous density. Contrast administration is necessary to demonstrate a patent lumen and suggests the correct diagnosis. Without contrast enhancement in the arterial phase, it is very difficult to establish the vascular nature of aneurysms, which is why the radiologist made an incorrect diagnosis. Recent advances in CT technology have allowed for a more accurate multiplanar and three-dimensional reconstruction, which shows the communication between the aneurysm sac and the blood vessels. High table speed and rapid image acquisition during contrast injection clearly show the arterial anatomy. On CT, large aneurysm can simulate pancreatic pseudocysts with fluid content. Blood clots and thrombotic deposits in aneurysms have a density similar to that of soft tissues or of high-density fluid collections.
Rupture is difficult to predict and nearly always fatal when it occurs. Other documented complications include thromboembolic events. The exact presentation depends on the degree of involvement of the branched vessels of the celiac artery. Concomitant nonvisceral arterial aneurysms have been previously reported to be a common finding in patients with CAA. Early recognition and intervention are crucial, because the operative mortality rate associated with ruptured CAA is 40% compared with only 5% for non ruptured aneurysms. On the basis of abdominal aortic aneurysm data, Rokke and colleagues found that the risk of CAA rupture can range from 5% for aneurysms that are from 15 to 22 mm in diameter to 50–70% for aneurysm with a diameter of more than 32 mm.
CAA can be treated either surgically or by endovascular interventional radiology techniques. Surgical repair is indicated for symptomatic aneurysms (i.e., aneurysms larger than 3 cm) or for patients in whom the aneurysm is enlarging rapidly. Surgical reconstruction, ablation via surgical ligation, intraluminal embolization, thrombin injection and endovascular grafting have all been reported with success. Routine follow-up CT angiography should be performed in incidentally detected cases in which only medical management is planned. Although no absolute size criteria are associated with significant rates of CCA rupture, Proposed indications for surgery include all symptomatic aneurysms, aneurysms that are increasing in size, aneurysms more than 3–4 times the normal vessel diameter (8 mm), and calcified aneurysms larger than 3 cm. Infectious etiologies, underlying collage vascular disease, anatomic features such as associated aneurysmal degeneration of the thoracic and abdominal aorta, coexistent visceral occlusive disease and physiologic factors such as patient age and cardiac, pulmonary and renal reserve all weigh in to treatment decision.
| Conclusions|| |
Although CAAs are rare entities, they are more frequently encountered as our use of cross-sectional imaging increases. The etiology of the aneurysm likely has an impact on the risk for rupture. An association with nonvisceral arterial aneurysms appears frequently. Benefits of MDCT can aid in planning for surgeries and other clinical interventions. Elective repair should be considered in good-risk patients with aneurysms of greater than 2 cm. Radiology department often called on to evaluate a patient with vague, non specific abdominal signs and symptoms. It is important to keep the diagnosis of visceral artery aneurysm in mind because of the grave consequences if rupture occurs.
We are also thankful to our librarian Jyotsana Suthar for literature search and submission.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Harsh C Sutariya
Assistant Prof. in Department of Radio Diagnosis and Imaging, G. R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre (IKDRC)-Dr. H. L. Trivedi Institute Of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
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