What is the management approach for a celiac artery penetrating ulcer?

Management of Celiac Artery Penetrating Ulcer

Immediate Assessment and Imaging

For a celiac artery penetrating ulcer, immediate contrast-enhanced CT angiography is essential to define the extent of the ulcer, assess for active bleeding or pseudoaneurysm formation, and evaluate patency of adjacent mesenteric vessels. 1

• Obtain CT angiography to identify the size and location of the penetrating ulcer, presence of pseudoaneurysm, active contrast extravasation, and involvement of branch vessels 1
• Assess for signs of visceral ischemia including bowel wall thickening, pneumatosis, or portal venous gas 1
• Evaluate the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) patency, as concurrent disease significantly impacts treatment decisions 1, 2

Treatment Algorithm Based on Clinical Presentation

Hemodynamically Unstable Patients with Active Bleeding

Immediate catheter angiography with endovascular intervention is the first-line approach for hemodynamically unstable patients or those with evidence of active extravasation. 1

• Proceed directly to angiography without delay if CT demonstrates active bleeding 1
• Endovascular options include covered stent-graft placement across the ulcer to exclude the pseudoaneurysm while maintaining celiac trunk patency 3, 4
• Custom-made fenestrated or scalloped stent grafts may be required if the ulcer involves the celiac trunk origin, allowing preservation of branch vessel perfusion 3, 4
• Technical success rates for endovascular stent placement range from 85-100% with lower perioperative risks compared to open surgery 2

Hemodynamically Stable Patients Without Active Bleeding

For stable patients without active extravasation, the decision between conservative management and intervention depends on ulcer size, growth rate, and presence of pseudoaneurysm. 4

• Conservative management with strict blood pressure control, antithrombotic therapy, and intensive surveillance is appropriate for small, stable ulcers without pseudoaneurysm 5, 6
• Target blood pressure control to reduce hemodynamic stress on the ulcer 5, 6
• Endovascular repair is indicated if the ulcer shows mean growth rate ≥5 mm per year or develops a pseudoaneurysm 4
• Serial imaging with CT angiography or MR angiography should be performed to monitor for vascular complications 1

Surgical Considerations

Open surgical repair is reserved for patients unsuitable for endovascular intervention, those with failed endovascular treatment, or when combined with other necessary abdominal surgery. 2

• Surgical options include celiac artery ligation with or without bypass, depending on collateral circulation adequacy 7
• Open aorto-celiac bypass may be necessary if ligation alone would result in visceral ischemia 7
• Assess collateral flow from the SMA via the pancreaticoduodenal arcade before considering ligation alone 7

Adjunctive Medical Management

Anticoagulation or antiplatelet therapy should be initiated in conjunction with definitive treatment planning, not as isolated therapy. 1

• Systemic anticoagulation prevents thrombus propagation but is not a surrogate for revascularization 1
• Anticoagulation has limited supporting data as sole therapy and should be complementary to definitive intervention 2, 8

Critical Monitoring and Follow-up

Visceral perfusion must be monitored clinically and radiologically with follow-up imaging to rule out complications. 1

• Perform follow-up CT angiography or MR angiography at regular intervals after intervention 1
• Monitor for signs of mesenteric ischemia including postprandial pain, weight loss, and food avoidance 2, 8
• Watch for late complications including stent migration, fracture, or endoleak requiring reintervention 9

Key Pitfalls to Avoid

• Do not delay imaging or intervention in unstable patients—immediate angiography is critical 1
• Do not use anticoagulation as sole therapy for penetrating ulcers with pseudoaneurysm or active bleeding 1, 2
• Do not assume adequate collateral circulation without angiographic confirmation before considering celiac artery sacrifice 7
• Ensure adequate proximal and distal sealing zones when planning endovascular repair, as short landing zones may require custom-made devices 4