Aortic Origins of the Celiac Trunk and Superior Mesenteric Artery

Prevalence of coeliac trunk variants: A systematic review with meta-analysis

BACKGROUND

The coeliac trunk (CoT) is an important branch of the abdominal aorta, that typically gives off the left gastric artery (LGA), the splenic artery (SA) and the common hepatic artery (CHA). Variations of the CoT are of great importance in clinical practice. The aim of the current systematic review with meta-analysis is to investigate the prevalence of these variants.

MATERIAL

A systematic review was performed in four online databases to identify studies referring to CoT variants prevalence. A meta-analysis was conducted by using the R programming software to calculate the pooled prevalence of the variants, and to detect possible parameters affecting them by using subgroup analysis.

RESULTS

The typical anatomy was considered the CoT with three branches (type 3) with a pooled prevalence of 83.39 %. The most common variation was the CoT with two branches (type 2) identified in 10.53 %. Rarest types were considered the CoT with four branches (type 4-1.80 %) and the CoT absence (type 1-0.43 %). A statistically significant difference according to the type of study (imaging or cadaveric) was identified for CoT type 1 and type 4. Overall, the most common variation was the hepato-splenic trunk calculated with a pooled prevalence of 6.68 %.

CONCLUSIONS

The current systematic review with meta-analysis investigated the CoT variants and proposed a classification system based on the number of branches emanating from the trunk. Knowledge of these variations is of paramount importance for anatomists, radiologists and surgeons frequently operating the abdominal organs.

Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta

PURPOSE

Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones.

METHODS

A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared.

RESULTS

The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25 mm for right, and 425 ± 28 to 440 ± 26 mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17 mm for right, and 229 ± 20 to 237 ± 19 mm for left) was predictive for zone 3 aorta.

CONCLUSION

Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.

Transverse and oblique course of the vertebral artery over the medullospinal junction

PURPOSE

The vertebral artery (VA) pierces the dura mater and continues with the intradural V4 segment. Once entered into the dura mater, the VA ascends from the infero-lateral to the antero-superior side of the medulla. Scarce reports of VAs compressing the medullospinal junction (MSJ) are available. We therefore aimed to determine the incidence of a course of the AV over the MSJ.

METHOD

One hundred sixty-two archived CT angiogram files were documented in the study. We recorded the cases in which the VA crossed the MSJ. We assessed the VA as dominant, non-dominant or co-dominant.

RESULTS

In 32 cases (19.75%), we identified intradural AVs on the ventral side of the MSJs. The incidence of this course of the VA was 17.1% in males and 23.81% in females. Of the 32 cases, the VA was non-dominant in 6, dominant in 14, and co-dominant in 12.

CONCLUSION

The VA course over the MSJ is not rare. Therefore, when specific neurological signs of MSJ or medulla compression are found, the course of the VA should be documented on CT or MRI angiograms.

Variations in origin level of superior mesenteric artery, inferior mesenteric artery, and coeliac trunk in Indian population

OBJECTIVE

The abdominal aorta is a continuation of the thoracic aorta and gives off the coeliac trunk, superior mesenteric artery, and inferior mesenteric artery. The focus of our study is to evaluate variations in the origin level in the coeliac trunk, superior mesenteric artery, inferior mesenteric artery, and aortic bifurcation in the Indian population and compare with various demographics.

METHODS

The study was retrospective and the local ethics committee approval was taken before starting it. Three hundred patients who were more than 18 years of age and required contrast-enhanced CT studies were included in this. The vertebral origin level of the arteries from the abdominal aorta and aortic bifurcation level was analysed.

RESULTS

The most common origin level of the coeliac trunk for both males and females was T12-L1 disc level. The most common origin level of the superior mesenteric artery was L1 upper level. The most common origin level of the inferior mesenteric artery was L3 upper level. The most common level of aortic bifurcation was L4 middle level. There was no statistical difference between the origin of any arteries in males and females in the Indian population.

CONCLUSION

As per our study of the Indian population and the published literature, it is realized that there are significant variations in the origins of the coeliac trunk, superior mesenteric artery, inferior mesenteric artery, and abdominal aorta bifurcation in different populations.

ADVANCES IN KNOWLEDGE

This study elaborates on potential anatomical variations in the Indian population, particularly the Mumbai city population. Also, our study compares it to different countries' data and their results in variations found in abdominal aorta branches.

A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery

PURPOSE

In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL).

METHODS

Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done.

RESULTS

Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties.

CONCLUSION

This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

Evaluation of the celiac trunk and its branching pattern by magnetic resonance angiography

OBJECTIVE

The study aimed to examine the celiac trunk (CT) in detail by magnetic resonance angiography, to determine the locations, positions and variations of the CT, to provide detailed information for surgeons and interventional radiologists, and to reduce the time spent in the catheter angiography.

MATERIAL AND METHODS

MR angiography images of 185 patients with abdominal imaging in PACS (Picture Archiving Communication Systems) were retrospectively analyzed. The level of origin of CT, according to the vertebral column, angle of origin, distance between CT and branches of the abdominal aorta (AA), and the branching pattern of CT were evaluated. Parameters were evaluated according to gender and age.

RESULTS

The most common origin site for CT, according to the vertebral column, was found to be at T12-L1 in both genders. There was a low, positive correlation between age and CT-Sagittal angle (SA) in the whole study group (p<0.05). The most common CT branching pattern was the hepatogastrosplenic trunk in both genders, according to Adachi and Uflkacker's classification. The distance between CT and the inferior mesenteric artery (IMA) and CT and the aortic bifurcation (AB) of males was greater than in females, and the differences were statistically significant (p<0.05).

CONCLUSION

Knowledge of the locations, positions, and variations of CT is essential in the diagnosis, differential diagnosis and decision-making mechanisms regarding the type of intervention to be performed for this vessel and related structures. In addition, the fact that data on these vessels can be obtained by MR angiography due to the improved image quality will prevent patients and physicians from the problems caused by the ionizing radiation of computed tomography. The data presented will constitute a basis for detailed and individualized interpretation and evaluation of each patient, as they provide important details about the configuration of the CT concerning gender and age using MRA.

Superior mesenteric artery revisited using magnetic resonance angiography

PURPOSE

We aimed to examine the superior mesenteric artery in detail by magnetic resonance angiography to provide an alternative to other imaging methods, to reduce the exposure time of patients and physicians to X-rays and the time spent in catheter angiography, to determine the variations, positions, and locations of the celiac trunk, and to provide detailed information for surgeons and interventional radiologists using this method.

METHODS

The procedures were approved by the Kocaeli University Medical School Non-Interventional Clinical Research Ethics Committee (10.04.2023, approval number: 2021/51). MR angiography images of 185 patients with abdominal imaging in PACS (Picture Archiving Communication Systems) were retrospectively registered. The level of origin of the superior mesenteric artery according to the vertebral column, angle of origin, distance between the superior mesenteric artery and branches of the abdominal aorta, and branching pattern of the superior mesenteric artery were evaluated. Parameters were evaluated according to gender and age using SPSS version 25.

RESULTS

The distance between superior mesenteric artery-inferior mesenteric artery and superior mesenteric artery-aortic bifurcation in males was higher than in females, and the difference was statistically significant. In females and the whole study group, a low, positive and significant relationship was found between age and superior mesenteric artery-sagittal angle. The most common origin site for the superior mesenteric artery, according to the vertebral column was found to be at L1 middle for males and L1 upper for females. The most common superior mesenteric artery branching pattern was classical type in both genders.

CONCLUSION

Individual evaluation of the superior mesenteric artery could reduce the risks during surgical interventions, considering the relationship of the superior mesenteric artery, especially with distally located vessels, and the gender differences for the angle of origin. Furthermore, considering that interventional radiologists choose the catheter according to the angle of origin of the artery during catheter angiography procedures, individual evaluation of patients taking into account gender and age is of utmost importance.

The Axial Spin of the Carotid Bifurcation

(1) Background: Twisted carotid bifurcations (CBs) lead to lateralized external carotid arteries (ECAs). Such variants are usually reported on a case-by-case basis. We aimed to study the anatomical possibilities of the axial spin of CB. (2) Methods: Determinations were made bilaterally on a retrospectively assessed sample of 150 cases, 88 males and 62 females. The following types of the axial spin of the CB were determined: type CK1-CB in the coronal plane, with ICA lateral of ECA; type CK3-CB in the coronal plane, with ECA lateral of ICA; the oblique type OK1, with the ECA antero-medial of ICA; the oblique type OK3a, with the ICA antero-medially; the oblique type OK3b, with the ICA postero-laterally; the sagittal type SK2a, with ECA anterior of ICA. (3) Results: In the overall group of 300 CBs, type OK1 was found in 40%, type OK3a in 1%, type OK3b in 2%, type CK1 in 9%, type CK3 in 5.67%, and type SK2a in 42.33% of the bilateral BC group. The types SK2a (46.67%) and OK1 (33.33%) prevailed on the right side. The types OK1 (46.67%) and SK2a (38%) prevailed on the left side. There was no statistically significant association between gender and left or right subtypes. A very strong symmetry existed between the left and right sides (Pearson Chi2 = 53.93 p < 0.001) for types OK1 and SK2a. Asymmetrical types were found in different bilateral combinations. (4) Conclusions: The spin of the CB is relatively symmetrical bilaterally, especially for the variants with the ECA antero-medial or anterior to ICA.

The Carotid-Hyoid Topography Is Variable

Background and Objectives: The carotid bifurcation (CB) is presented in most anatomy textbooks as having a unique location at the upper margin of the thyroid cartilage. Although a number of case reports have provided evidence of the possibility of carotid artery location either lateral or medial to the greater hyoid horn, these reports have not established specific anatomic possibilities and prevalences. Materials and Methods: We retrospectively analysed a batch of 147 CT angiograms for 12 types of carotid-hyoid relationships and classified the bilateral combination possibilities of these types. Results: In 168/294 sides there were no carotid-hyoid relationships. Type I, external carotid artery (ECA) medial to the greater horn of the hyoid bone (GHHB), was observed in 0.34%; type II, internal carotid artery (ICA) medial to GHHB, in 0.34%; type III, ICA and ECA medial to GHHB, in 1.02%; type IV, common carotid artery (CCA) medial to GHHB, in 1.02%; type V, CB medial to GHHB, in 0.34%; type VI, ECA lateral to GHHB, in 20.41%; type VII, ICA lateral to GHHB, was not recorded; type VIII, ECA and ICA lateral to GHHB, in 3.74%; type IX, CCA lateral to GHHB, in 8.5%; type X, CB lateral to GHHB, in 6.46%; type XI, ECA lateral and ICA medial to GHHB, in 0.34%; and type XII, ICA lateral and ECA medial to GHHB, in 0.34%. Bilateral symmetry was found in 70.74% of cases, including the null types without carotid-hyoid relationships as well as types IV, VI, VIII, IX, and X. There was a highly significant association between the left and right variants of the carotid-hyoid relationship. Conclusions: Mechanical compression of the hyoid bone on the carotid arteries has various undesirable effects on the ICA and cerebral circulation. Underlying these are several variational anatomical patterns of carotid-hyoid relationships, which can be accurately documented on CT angiograms. A case-by-case anatomical study is better than assuming the carotid anatomy learned from textbooks.

Development of a Novel Scoring Model to Estimate the Severity Grade of Mesenteric Artery Stenosis

Objective: This study aimed to derive a new scoring model from estimating the severity grade of mesenteric artery stenosis. We sought to analyze the relationship between the new scoring model and the development, treatment, and mortality of chronic mesenteric ischemia (CMI). Methods: This retrospective study included 242 patients (128 (53%) women and 114 (47%) men) with suspected CMI from January 2011 to December 2020. A weighted sum six-point score (CSI-score; the celiac artery is abbreviated by “C”, superior mesenteric artery by “S”, and inferior mesenteric artery by “I”) based on the number of affected vessels and the extent and grade of the stenosis or occlusion of the involved visceral arteries was derived by maximizing the area under the ROC curve. The calculated CSI-score ranged from 0 to 22. The patients were divided according to the best cut-off point into low-score (CSI-score < 8) and high-score (CSI-score ≥ 8) groups. Results: The area under the receiver operating characteristic curve (AUC) of the CSI-score was 0.86 (95% CI, 0.82−0.91). The best cut-off point of “8” represented the highest value of Youden’s index (0.58) with a sensitivity of 87% and specificity of 72%. The cohort was divided according to the cut-off point into a low-score group (n = 100 patients, 41%) and high-score group (n = 142 patients, 59%) and according to the clinical presentation into a CMI group (n = 109 patients, 45%) and non-CMI group (n = 133 patients, 55%). The median CSI-score for all patients was 10 (range: 0 -22). High-scoring patients showed statistically significant higher rates of coronary artery disease (54% vs. 36%, p = 0.007), chronic renal insufficiency (50% vs. 30%, p = 0.002), and peripheral arterial disease (57% vs. 16%, p < 0.001). A total of 109 (45%) patients underwent invasive treatment of the visceral arteries and were more often in the high-score group (69% vs. 11%, p < 0.001). Of those, 79 (72%) patients underwent primary endovascular treatment, and 44 (40%) patients underwent primary open surgery or open conversion after endovascular treatment. Sixteen (7%) patients died during the follow-up, with a statistically significant difference between high- and low-scoring patients (9% vs. 0%, p = 0.008). The score stratification showed that the percentage of patients treated with endovascular and open surgical methods, the recurrence of the stenosis or failure of the endovascular treatment, the need for a bypass procedure, and the mortality rates significantly increased in the subgroups. The CSI-score demonstrated an excellent ability to discriminate between patients who needed treatment and those who did not, with an AUC of 0.87 (95% CI, 0.82−0.91). Additionally, the CSI-score’s ability to predict the patients’ mortality was moderate, with an AUC of 0.73 (95% CI, 0.62−0.83). Conclusions: The new scoring model can estimate the severity grade of the stenosis of the mesenteric arteries. Our study showed a strong association of the score with the presence of chronic mesenteric ischemia, the need for treatment, the need for open surgery, and mortality.