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Findings: (A,B, and C) Sequential AP views of the abdominal aortogram demonstrates first filling of the SMA and the hypertrophied gastroduodenal artery, then delayed retrograde opacification of the hepatic, left gastric, and splenic arteries. Atherosclerotic narrowing is seen in the proximal portion of the splenic artery and the renal arteries bilaterally. (D) Lateral view shows complete occlusion of the celiac axis.

Diagnosis: Celiac stenosis with collateral flow from gastroduodenal artery.

Discussion: The celiac axis normally arises anteriorly from the abdominal aorta at T12-L1, approximately 2 mm to 2 cm above the origin of the superior mesenteric artery. The classic branching pattern of the celiac trunk (in 65-75% individuals) is the left gastric, common hepatic, and splenic arteries. The common hepatic branches first into the gastroduodenal then proper hepatic artery. The gastroduodenal artery gives rise to the posterior superior pancreaticoduodenal, and more distally, the anterior superior pancreaticoduodenal artery. Both the anterior and posterior superior pancreaticoduodenals anastomose with the anterior and posterior branches of the inferior pancreaticoduodenal artery (from the superior mesenteric artery) to form the pancreaticoduodenal arcades. There are usually two arcades (80%), one on both the anterior and posterior of the pancreas, but there may also be a one, three, or four.

In addition to the collateral circulation through the gastroduodenal, collaterals in celiac stenosis arise from the dorsal pancreatic artery. It may anastomose with the middle colic or accessory middle colic arteries, branches of the superior mesenteric artery.

Radiologic evidence of celiac stenosis, whether due to a congenital absence, atherosclerosis or compression by the median arcuate ligament, is not always associated with mesenteric ischemia. The patient in the case above developed sufficient collateral circulation and did not experience any ischemic symptoms.

Celiac stenosis can also cause pancreaticoduodenal artery aneurysms because of the increased flow through the collateral circulation. Rupture of these aneurysms can be dangerous and lead to formation of a peripancreatic hematoma or hemoperitoneum.

References:
Kadir S. Atlas of Normal and Variant Angiographic Anatomy.
W. B. Saunders Co. Philadelphia; 1991-101, 297-364.

Quandalle P, Chambon JP. Marache P, Saudemont A, and Maes B.
Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis:
report of two cases and review of the literature. Ann Vasc Surg 4:540-545, 1990.

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