What are the typical presentation and management of coeliac artery occlusion?

Coeliac Artery Occlusion: Presentation and Management

Coeliac artery occlusion is often asymptomatic due to collateral circulation from the superior mesenteric artery through the pancreaticoduodenal arcade, but when symptomatic, it typically presents with postprandial abdominal pain, weight loss, and food aversion. 1, 2

Clinical Presentation

Asymptomatic Occlusion

• Celiac axis narrowing occurs in approximately 20% of the general population 2
• Most cases remain asymptomatic due to collateral circulation development 3

Symptomatic Presentation (Chronic Mesenteric Ischemia)

• Postprandial abdominal pain (classic symptom)
• Weight loss (significant predictor of disease when ≥20 pounds)
• Food aversion despite preserved appetite (distinguishing from malignancy)
• Diarrhea or constipation
• Physical examination may reveal an abdominal bruit 1

Laboratory Findings

• Non-specific findings may include:
  • Anemia
  • Leucopenia
  • Electrolyte abnormalities
  • Hypoalbuminemia (secondary to malnutrition) 1

Diagnostic Approach

First-Line Imaging

• CT Angiography (CTA) is recommended as the first-line imaging modality
  • Sensitivity and specificity of 94-95% for diagnosing mesenteric artery occlusion
  • Should include both arterial and venous phases with 1mm slices 1
  • Can show characteristic "J-shaped" narrowing in MALS (Median Arcuate Ligament Syndrome) 2

Additional Imaging

• Duplex Doppler Ultrasound:

  • Useful as a screening tool and for follow-up
  • Should be performed in specialized centers by skilled operators
  • Can demonstrate respiratory variation in celiac artery flow 2

• Mesenteric Angiography:

  • Confirms diagnosis and allows assessment of collateral circulation
  • Should be performed in lateral projection during both inspiration and expiration 2

Management

Asymptomatic Disease

• No indication for prophylactic revascularization in asymptomatic patients 1

Symptomatic Disease

1. For Median Arcuate Ligament Syndrome (MALS):

   • Surgical release of the median arcuate ligament is first-line treatment
   • Provides symptomatic relief in 84.6% of patients
   • Best outcomes in patients with postprandial pain, age 40-60 years, and significant weight loss 2

2. For Atherosclerotic Occlusion (Chronic Mesenteric Ischemia):

   • Prompt revascularization is recommended (delay can lead to clinical deterioration)
   • Endovascular therapy (angioplasty and stenting) has become first-line treatment
     • Lower postoperative mortality compared to open surgery
   • Open mesenteric bypass offers:
     • Improved patency
     • Lower re-intervention rates
     • Better freedom from recurrent symptoms 1

3. For Acute Occlusion:

   • Immediate revascularization is essential for survival
   • Endovascular therapy should be considered first-line for thrombotic occlusion
   • Both endovascular and open surgical approaches are appropriate for embolic occlusion 1

Complications and Special Considerations

• Development of collateral circulation, visceral artery aneurysms, and aneurysm rupture are potential complications 2
• Celiac artery occlusion is critical to identify before pancreaticoduodenectomy, as removal of the pancreaticoduodenal arcade can result in ischemia of the liver, stomach, and residual pancreas 4, 5
• Complications of endovascular treatment include:
  • Distal mesenteric embolization
  • Branch perforation
  • Dissection
  • Stent dislodgement
  • Stent thrombosis 1

Follow-up Recommendations

• Clinical evaluation at 1,3,6, and 12 months after intervention
• Duplex ultrasound or CTA at 6 months and annually thereafter to assess patency 2

Early diagnosis and appropriate management are crucial to prevent progression to bowel infarction and improve outcomes in patients with coeliac artery occlusion.