Abstract
A 50-year-old man presented with right upper abdominal pain after an ultrasound-guided puncture of an unclear liver lesion. Computed tomographic angiography revealed a large perihepatic hematoma with suspected active bleeding. Additionally, separate origins of the common hepatic artery (Panel A, black arrowhead), left gastric artery (Panel A, arrow), and splenic artery from the aorta (Panel A, white arrowhead) were observed with a lumen narrowing of the common hepatic artery at the level of the diaphragmatic crus (Panel B, arrow) without any signs of atherosclerosis. The patient underwent an emergency embolization procedure. The angiography from the origin of the common hepatic artery showed almost complete stenosis and extensive collaterals (Panel C, arrowheads) to the proper hepatic artery through branches of the superior mesenteric artery (Panel C, arrow; supplemental video 1). The catheter was advanced into the common hepatic artery during deep inspiration. Angiographic images after advancement of the catheter into the common hepatic artery show normal hepatic arterial anatomy with the inflow of unenhanced blood through the gastroduodenal artery (Panel D, arrow; supplemental video 2). The patient underwent a successful coil embolization. Owing to the absence of indications for liver ischemia, no actions were deemed necessary regarding common hepatic artery compression.
Celiac truncus develops during the first trimester by coalescence of the paired ventral segmental arteries. Several anatomical variations have been reported in the branching of the celiac artery due to mismatching during this process. 1 Agenesis of the celiac artery is an extremely rare anatomical variation. The median arcuate ligament syndrome is seen due to compression of the celiac artery by the median arcuate ligament which links the right and left diaphragmatic crura. Severe compression leading to collateral development is seen in 1% of the population. 1 Although it can be asymptomatic, like in our case, it is crucial for the planning of the endovascular procedure, especially when another rare variation of celiac artery agenesis accompanies it. In our case, catheterization of the common hepatic artery was only possible during deep inspiration of the patient due to increased compression at expiration. 2 In such cases, increased flow through pancreaticoduodenal collaterals can lead to aneurysm formation and bleeding. 3 This variation may also have implications for patients undergoing repair of a thoracoabdominal aneurysm.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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References
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