Celiacomesenteric Trunk: A Rare Anatomical Variation With Potential Clinical and Surgical Implications
Guillermo Sangster, MD; Sandra Ramirez, MD; Carlos Previgliano, MD; Aya Al Asfari, MD; Alireza Hamidian Jahromi, MD; Alberto Simoncini, MD
The arterial supply of the abdominal viscera is derived via three single arteries: the celiac axis, the superior mesenteric artery, and the inferior mesenteric artery. These arteries usually originate separately from the ven- tral aspect of the abdominal aorta. In some cases, two or more of these arteries may originate from a common trunk. The celiacomesenteric trunk is a rare condition that can generate clinical and surgical complications. Preoperative knowledge of vascular anomalies is critical when planning a surgical approach. We report a patient who underwent Multi-detector Computed Tomography (MDCT) before a vascular procedure, and a common trunk for celiac axis and superior mesenteric artery (celiac mesenteric trunk) was incidentally found.
CASE PRESENTATION A 70-year-old white male presented to the emergency department complaining of two days history of severe pain in the left lower extremity. Physical examination revealed a blood pressure of 154/102, a pulse rate of 81 per min, and a cool left foot with 2+ femoral and radial pulses. There were no palpable/dopplerable posterior tibial and dorsa- lis pedis pulses present in the left leg. A diagnosis of left lower extremity ischemia was made, and the patient was started on a Heparin drip. The patient was also found to have a pulsatile mass in his abdomen. He was considered a candidate for surgery, and a computed tomographic angiogram (CTA) of the abdomen and pelvis with lower extremity runoff was performed. The examination revealed a 5.5 cm fusiform infra-renal abdominal aortic aneurism and peripheral vascular disease with occlusion of left popliteal artery above the knee. Reconstitution of the contrast flow below the popliteal artery and runoffs was found. The CTA incidentally depicts a common origin for the celiac axis and SMA from the abdominal aorta (celiacomesenteric trunk) (Figures 1, 2). The origin of the inferior mesenteric artery was unremarkable. DISCUSSION In classic anatomy, the celiac trunk originates anteriorly from the abdominal aorta at T12 level, just as the aorta enters the abdomen. It divides into three branches: the left gastric artery, the splenic artery, and the common hepatic artery. The celiac axis gives arterial supply to the liver, gallbladder,
spleen, pancreas, and gut from the distal esophagus to the ampullary region. 1,2 The SMA arises anteriorly from the abdominal aorta at L1 level, 1 to 2 cm below the celiac artery, immediately superior to the origin of the renal arteries. The SMA courses behind the pancreatic body where it enters the mesentery and supplies the distal duodenum, jejunum, ileum, and colon from the cecum to the mid transverse portion. 1 Variant arterial anatomy is common, occurring in nearly half of the population. 3 However, a common origin for the celiac and superior mesenteric arteries (celiacomesenteric trunk) is seen in less than 1% of patients. 1,3 The presence of a common trunk has important clinical implications. Apatient with this anomaly lacks the collateral protection of a dual vascular supply to the abdominal viscera. Atherosclerosis or complications of a vascular interventional procedure can place the abdominal viscera at risk. 4 In cases where a liver transplant is planned, or when a surgical management of patients with pancreatic and hepato-biliary neoplasms is arranged, recognition of these vascular anomalies may significantly affect the surgical approach. 4-6 It has also been shown that there is an increased risk of hepatic artery complications after liver transplantation, as well as during chemo-embolization in patients with mesenteric arterial variants. 7.8 During embryonic development, the 10th to 13th vi- telline arteries (primitive intestinal arteries) communicate between the aorta and a primitive ventral anastomotic artery. Typically the ventral anastomosis and the 11th and 12th vitelline arteries regress, while the 10th and 13th roots give origin to the celiac trunk and the SMA, respectively.
J La State Med Soc VOL 166 March/April 2014 53
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