What are the management options for celiac artery disease?

Management of Celiac Artery Disease

For symptomatic celiac artery stenosis, the treatment approach depends on etiology: surgical release of the median arcuate ligament is first-line for median arcuate ligament syndrome (84.6% symptomatic relief), while endovascular angioplasty with stent placement is first-line for atherosclerotic disease (85-100% technical success). 1

Initial Diagnostic Workup

CT angiography is the initial imaging modality of choice to evaluate:

• Proximal celiac artery narrowing with "J-shaped" configuration (suggests median arcuate ligament compression) 1
• Atherosclerotic changes with calcification 1
• Presence and extent of collateral circulation 1

For suspected median arcuate ligament syndrome, mesenteric angiography in lateral projection during both inspiration and expiration demonstrates dynamic worsening of stenosis on expiration, which is pathognomonic for this condition 1, 2

Management Algorithm Based on Clinical Presentation

Asymptomatic Celiac Artery Stenosis

Observation with supportive measures only is recommended for asymptomatic patients, as celiac artery compression is present in approximately 20% of the general population and is often a normal anatomic variant 2

Do not intervene based on imaging findings alone - compression may be incidental rather than pathologic 2

Symptomatic Celiac Artery Stenosis

Classic symptoms warranting intervention include:

• Postprandial abdominal pain occurring 30-60 minutes after meals 2
• Weight loss (particularly ≥20 pounds) 2
• Food avoidance due to pain (sitophobia) 2
• Nausea and vomiting worsening after meals 1

Treatment Based on Etiology

Median Arcuate Ligament Syndrome

Surgical release of the median arcuate ligament is first-line treatment, achieving symptomatic relief in 84.6% of patients 1

Additional revascularization should be considered if residual stenosis exceeds 30% after ligament release, with options including:

• Endovascular stent placement 1
• Surgical bypass creation 1

Predictors of successful surgical outcomes include:

• Postprandial pain pattern (81% cure rate) 2
• Age 40-60 years (77% cure rate) 2
• Weight loss ≥20 pounds (67% cure rate) 2

Atherosclerotic Celiac Stenosis

Endovascular therapy with angioplasty and stent placement is first-line treatment, with technical success rates of 85-100% and lower perioperative risks compared to open surgery 1, 3

Surgical bypass or endarterectomy is appropriate (rating 7/9) but typically reserved for:

• Patients unsuitable for endovascular intervention 1
• Multi-vessel disease requiring urgent intervention 1
• When combined with other abdominal surgery 1

Multi-Vessel Disease Requiring Urgent Intervention

Angiography with percutaneous transluminal angioplasty and stent placement is usually appropriate (rating 8/9) for urgent multi-vessel disease 1

Systemic anticoagulation alone (rating 5/9) may be complementary but should not be sole therapy 1, 2

Special Clinical Scenarios

Celiac Artery Aneurysms

Elective repair should be considered in good-risk patients with aneurysms greater than 2 cm, as rupture does occur despite rarity 4

Prosthetic grafts are the conduit of choice for noninfected aneurysms, with excellent long-term results 4

Spontaneous Isolated Celiac Artery Dissection

Most patients can be treated conservatively first with strict blood pressure control, antithrombotic therapy, and intensive surveillance 5, 6

For patients with aneurysmal dilatation (≥12.5 mm diameter) or failed conservative treatment, endovascular stent grafts can be used without affecting branch blood supply 5

Critical Pitfalls to Avoid

Never perform endovascular intervention alone for median arcuate ligament syndrome without surgical release - this leads to poor outcomes due to persistent extrinsic compression, chronic vessel wall changes, and risk of stent fracture or migration 1, 2

Do not rely on systemic anticoagulation for median arcuate ligament compression without evidence of thrombosis - limited data supports this approach 1, 2

Consider alternative diagnoses if symptoms persist after intervention - celiac compression may be incidental rather than causative in up to 20% of cases 1

Recognize that collateral circulation through pancreaticoduodenal arcades from the superior mesenteric artery often prevents clinically significant ischemia despite severe celiac stenosis/occlusion 7