What is the appropriate management for an adult patient with stenosis of the celiac trunk and risk factors for atherosclerosis?

Management of Celiac Trunk Stenosis

For adult patients with celiac trunk stenosis and atherosclerotic risk factors, endovascular therapy with angioplasty and covered balloon-expandable stent placement is the first-line treatment, achieving technical success rates of 85-100% with lower perioperative risks than open surgery. 1

Initial Diagnostic Workup

CT angiography (CTA) is the initial imaging modality of choice, with 95-100% sensitivity and specificity for detecting mesenteric vascular abnormalities. 1 The imaging must specifically evaluate:

• Atherosclerotic calcified plaque at the celiac origin versus "J-shaped" proximal narrowing suggesting median arcuate ligament (MAL) compression 1
• Presence and extent of collateral circulation, particularly pancreaticoduodenal arcades from the superior mesenteric artery (SMA), as these provide rich collateral flow that often keeps patients asymptomatic 1, 2
• Involvement of other mesenteric vessels (SMA, inferior mesenteric artery), as multi-vessel disease significantly impacts treatment decisions 1

For suspected MAL syndrome specifically, mesenteric angiography with lateral projection during both inspiration and expiration should be performed to demonstrate dynamic worsening of stenosis on expiration. 3

Treatment Algorithm Based on Etiology and Severity

Atherosclerotic Celiac Trunk Stenosis

Endovascular therapy with angioplasty and stent placement is first-line treatment for atherosclerotic disease, with covered balloon-expandable stents recommended for optimal outcomes. 1 This approach achieves:

• Technical success rates of 85-100% 1, 3
• Lower perioperative risks compared to open surgical intervention 3

Systemic anticoagulation serves only as adjunct therapy to prevent thrombotic complications and is not a surrogate for revascularization. 1

Median Arcuate Ligament Syndrome

Surgical release of the median arcuate ligament is the first-line treatment for MAL syndrome, associated with symptomatic relief in 84.6% of patients. 3

Additional revascularization after MAL release should be considered if residual stenosis exceeds 30%, with options including endovascular stent placement or surgical bypass creation. 3, 4

Multi-Vessel Disease

For multi-vessel disease requiring urgent intervention:

• Angiography with percutaneous transluminal angioplasty and stent placement is rated as usually appropriate (8/9), with priority given to treatment of the SMA 1, 3
• Surgical bypass or endarterectomy is also appropriate (7/9) as an alternative 1, 3
• Systemic anticoagulation alone (rating 5/9) may be complementary but should not be sole therapy 3

Mild Stenosis (30-40%)

Medical management alone is recommended for mild stenosis in asymptomatic patients, including:

• Blood pressure control, lipid management with statins, diabetes control, and smoking cessation 4
• Antiplatelet therapy with aspirin or clopidogrel for atherosclerotic disease 4
• No revascularization is indicated for stenosis <50% regardless of etiology 4

Critical Pitfalls to Avoid

Never perform endovascular stenting alone for MAL-related stenosis without surgical ligament release first, as persistent extrinsic compression causes stent fracture, migration, or slippage. 3, 4

Do not attribute symptoms to celiac stenosis without excluding other pathology, as celiac compression is present in approximately 20% of the population on imaging without symptoms and may be an incidental finding. 1, 3, 4

Alternative diagnoses must be thoroughly investigated if symptoms persist after intervention, as celiac compression may not be causative. 1, 3

Special Clinical Scenarios

In patients undergoing duodenopancreatectomy with celiac trunk stenosis, significant complications can develop when pancreaticoduodenal arcade arteries are ligated, as this eliminates the collateral blood supply from the SMA. 5, 6 Preoperative evaluation and potential correction of significant celiac stenosis should be considered before pancreatic surgery. 6

For interventional radiology procedures requiring hepatic arterial access (such as chemoembolization), dilation of the pancreaticoduodenal arcade from the SMA may provide an alternative access route when celiac stenosis is present. 2