Management of Celiac Trunk Aneurysm
All celiac trunk aneurysms should be treated due to their significant rupture risk (14% mortality when ruptured), with endovascular repair preferred when anatomically feasible, and open surgical reconstruction reserved for complex anatomy or endovascular failure. 1, 2
Treatment Indications
Intervention is recommended for all celiac trunk aneurysms regardless of size due to the unpredictable natural history and high rupture mortality. 1 Celiac artery aneurysms account for only 4% of visceral aneurysms, making them extremely rare but clinically significant. 3, 1
Key Risk Factors
- Rupture mortality reaches 14% in general populations 1
- Asymptomatic presentation is common, with many discovered incidentally on imaging 2
- Symptomatic patients may present with abdominal pain or acute rupture 1
Treatment Approach Algorithm
First-Line: Endovascular Repair
Endovascular treatment should be the preferred approach when technically feasible based on improved outcomes and lower morbidity. 1, 4
Technical considerations:
- Stent-graft deployment across the aneurysm with preservation of branch vessels 4
- Multilayer stents can maintain patency of hepatic and splenic arteries while achieving aneurysm thrombosis 4
- Technical success rates for catheter-based interventions range from 67-100% 3
- Monitor closely for abdominal pain post-procedure, which may indicate complications 3
Common pitfall: Stent migration to splanchnic branches can occur but may be clinically insignificant. 1 Follow-up imaging at 12 months should confirm stent patency, complete sac thrombosis, and preserved perfusion of liver and spleen. 4
Second-Line: Open Surgical Repair
Open surgical reconstruction is indicated when:
- Aneurysm size or anatomic features make endovascular approach risky or technically unfeasible 1, 2
- Proximal location with complex celiacomesenteric trunk anatomy precludes safe endovascular treatment 2
- Endovascular treatment has failed 1
Surgical options include:
- Interposition grafting with great saphenous vein 2
- Antegrade bypass from the aorta 4
- Simple ligation (in select cases) 1
- Direct repair or resection 1
Surgical approach advantages: Lower risk of visceral branch occlusion makes it safer and more reliable than endovascular treatment in complex anatomy. 2
Hybrid Approach
Consider hybrid surgical-endovascular procedures for complex cases:
- Reno-splenic bypass combined with stent-graft deployment via direct splenic artery approach 5
- This preserves visceral perfusion while achieving aneurysm exclusion 5
Special Considerations
Associated Celiac Trunk Stenosis
When celiac trunk stenosis from median arcuate ligament compression is present:
- Immediate embolization during arteriography is most effective for ruptured aneurysms 6
- Surgical sectioning of the arcuate ligament should follow to decompress the celiac artery and prevent recurrence 6
- This two-stage approach addresses both the acute bleeding and underlying causative pathology 6
Diagnostic Workup
Pre-treatment imaging sequence:
- Initial detection via ultrasonography or CT scan 1, 2
- CT angiography for anatomic detail and surgical planning 2
- Diagnostic arteriography if endovascular treatment is planned 1
In unstable patients with suspected acute aortic syndrome, transesophageal echocardiography is recommended for evaluation of the celiac trunk and mesenteric arteries. 7
Expected Outcomes
Endovascular repair:
- Zero mortality in reported series 1
- Hospital stay approximately 4 days 1
- Minor complications include stent migration (usually without clinical consequence) 1
Open surgical repair:
- Zero mortality in contemporary series 1, 2
- Hospital stay approximately 13 days 1
- Minor complications include pulmonary thickening with pleural effusion (spontaneous resolution) 1
- Uneventful postoperative courses with maintained graft patency 2