What is the management approach for celiac arterial stenosis?

Management of Celiac Arterial Stenosis

For patients with symptomatic celiac arterial stenosis, surgical release of the median arcuate ligament with possible revascularization is the recommended first-line treatment, as it provides symptomatic relief in up to 84.6% of cases. 1

Etiology and Clinical Presentation

• Celiac arterial stenosis can be caused by:

  • Median arcuate ligament (MAL) compression - present in approximately 20% of the population 1
  • Atherosclerotic disease 1
  • Tumor infiltration or lymphadenopathy in malignant disease 2

• Common symptoms include:

  • Postprandial abdominal pain
  • Weight loss
  • Nausea and vomiting that worsens after meals 1
  • Fear of eating (sitophobia) 1

Diagnostic Approach

• CT angiography (CTA) is the initial imaging modality of choice, looking for:

  • Proximal narrowing of the celiac artery in a "J-shaped" configuration (in MAL syndrome) 1
  • Atherosclerotic changes 1
  • Presence of collateral circulation 1

• Mesenteric angiography with lateral projection during both inspiration and expiration:

  • Demonstrates dynamic worsening of stenosis on expiration (in MAL syndrome) 1
  • Identifies mesenteric collateralization (patients with collateralization are less likely to benefit from MAL release) 1

Management Algorithm

1. For Median Arcuate Ligament Syndrome

• First-line treatment: Surgical release of MAL

  • Associated with symptomatic relief in 84.6% of patients 1
  • Can be performed laparoscopically with good outcomes 3
  • Consider in patients with postprandial pain pattern, age between 40-60, and weight loss >20 pounds (predictors of successful outcomes) 1

• Additional revascularization after MAL release

  • Consider if residual stenosis of celiac artery >30% after surgical release 1
  • Options include:
    • Endovascular stent placement 1
    • Surgical bypass creation 1
  • Patients who undergo revascularization in addition to decompression have higher rates of symptom resolution (76% vs 53%) 1
  • However, some studies show no significant difference in symptom relief between decompression alone vs. decompression with revascularization at 5-year follow-up 1

2. For Atherosclerotic Celiac Stenosis

• Endovascular therapy (angioplasty with stent placement)

  • First-line treatment for atherosclerotic disease 1
  • Technical success rates of 85-100% 1
  • Lower perioperative risks compared to open surgical intervention 1
  • However, associated with higher rates of restenosis and recurrent symptoms 1

• Open surgical repair

  • Consider when endovascular approach is not possible 1
  • Options include bypass or endarterectomy 1
  • Higher risk of in-hospital complications (relative risk 2.2) 1
  • Better long-term outcomes with higher 5-year survival rates 1

Special Considerations

• Pancreaticoduodenal artery aneurysms (PDAAs) with celiac stenosis

  • PDAAs often develop secondary to celiac stenosis and can rupture with fatal consequences 4
  • Treatment options:
    • Embolization of the aneurysm 4
    • Subsequent stenting of the celiac artery if symptoms of gastric ischemia develop 4

• Celiac stenosis during pancreaticoduodenectomy

  • Can cause ischemic threat to liver, stomach, and spleen when gastroduodenal artery is ligated 2
  • Management options include:
    • Endovascular dilatation 2
    • Arterial reconstruction 2

Pitfalls and Caveats

• Endovascular intervention alone (without surgical release) is not recommended for MAL syndrome due to:

  • Persistent extrinsic compression 1
  • Chronic changes to the vessel wall from repeated stress 1
  • Risk of stent fracture or migration 1

• Systemic anticoagulation has limited data to support its use in patients with MAL compression without evidence of thrombosis 1

• Not all patients with imaging evidence of celiac compression are symptomatic - compression may be a normal finding in up to 20% of the population 1

• Consider alternative diagnoses if symptoms persist after intervention, as celiac compression may be an incidental finding rather than the cause of symptoms 1