Findings:

1. High-grade stenosis of the celiac artery approximately 1 cm from its origin
   noted on lateral view. AP view demonstrates collateral filling the gastroduodenal via
   the interior pancreaticoduodenal arcade off the SMA.
2. Infrarenal abdominal aortic aneurysm.
3. Partial left nephrectomy.

Discussion: Abdominal angina is controversial and uncommon entity, usually seen in older patients as a complication of atherosclerotic disease. The intermittent abdominal angina is provoked by food ingestion as a result of intermittent mesenteric ischemia and anoxia brought on by the increased demand on the splanchnic circulation by digestion. Characteristically, patients give a history of weight loss since they decrease intake to avoid the pain "abdominal angina". Characteristically pain starts 1-2 hours after the ingestion of food, which increases in severity over time. Over time symptoms worsen. The ischemia produces mucosal and mural deterioration leading to malabsorption and diarrhea which aggravate the weight loss. Infrequently nausea and vomiting are present.

More than two thirds of the patients have concomitant peripheral vascular disease and aneurysmal dilatation of the abdominal aorta. Occasionally fibromuscular dysplasia may be the cause of symptomatology. It is important not to mistake extrinsic compression of the celiac artery by the median cruciate ligament of the diaphragm as a stenotic lesion. This can easily be avoided by performing lateral views in expiration when such lesions disappear. Furthermore, these lesions are not circumferential and are limited to a characteristic concave impression on the cranial surface of the celiac artery just beyond its origin. The diagnosis requires clinical history and the presence of a stenotic lesion. Identification of a stenosis alone without symptoms should not be a cause for concern. Patients with adequate collateral circulation frequently remain asymptomatic. In these patients, knowledge of the lesion may be important in the future when preexisting stenosis and systemic low flow states due to cardiac failure and/or intra-operative hypotension result in nonocclusive mesenteric ischemia which may be potentiated by the presence of celiac stenosis. Some of these cases may progress to bowel infarction.

Although it was originally felt that stenosis or occlusion of two or more of the celiac, SMA and IMA were necessary to cause symptoms, Morris, et al., 1966 demonstrated that celiac artery stenosis alone could be sufficient to cause symptoms.

Uncommon causes of abdominal angina:

1. Aneurysms of SMA and hepatic arteries (Dunbar et al, 1965).
2. Fibromuscular hyperplasia of the celiac artery (Palubinskas and Ripley, 1964).
3. Congenital celiac artery occlusion.
4. Post surgical adhesions, inflammatory disease (Johnsson, 1962) or neoplastic
   encasement causing vascular stenosis.

References:

1. Castaneda-Zuniga W, et al. Interventional Radiology.
   Williams & Wilkins; 1992:359-363.
2. Netter FH. Atlas of Human Anatomy. Ciba-Geigy Corp; 1989.
3. Morris GC Jr, Debalcey ME & Bernhard V. Abdominal Angina.
   Surgical Clinics of North America. 1966;46:919.
4. Reuter & Redman. Gastrointestinal Angiography. W. B. Saunders
   Company; 1972:72-74.