Clinics in diagnostic imaging (176). Acute embolic occlusion of the coeliac artery

Abstract

A 52-year-old man, who had a background of chronic heart disease and atrial fibrillation, as well as non-compliance with warfarin therapy, presented with a two-week history of worsening upper abdominal pain. Computed tomography mesenteric angiography showed complete embolic occlusion of the coeliac artery with resultant segmental splenic infarction, and thrombus within the left ventricle. A decision was made to proceed with catheter-directed thrombolysis. Subsequent follow-up angiogram at 12 hours showed successful treatment with complete dissolution of the coeliac embolus. The patient's symptoms resolved during his hospitalisation and he was subsequently discharged well on long-term oral anticoagulation therapy. Isolated acute embolic occlusion of the coeliac axis is a rare occurrence that may result in end-organ infarction. Treatment options include systemic anti-coagulation, mechanical thrombectomy, catheter thrombolysis or open surgery. Catheter-directed thrombolysis therapy is a feasible and effective option for treating acute thromboembolic occlusion of the coeliac artery.

Keywords: atrial fibrillation; catheter-directed thrombolysis; coeliac artery occlusion; embolus.

Fig. 1

Axial CT images in (a) arterial and (b) delayed phases through the upper abdomen.

Fig. 2

Axial CT image at the level of the heart.

Fig. 3

Axial CT image through the upper abdomen.

Fig. 4

(a) Selective angiogram of the coeliac artery shows a filling defect within, extending into the common hepatic and splenic arteries; distal opacification of the hepatic artery proper occurs via retrograde flow through the superior mesenteric artery and gastroduodenal artery. (b) Angiogram of the coeliac artery shows that the guiding catheter was placed in the ostium of the coeliac artery with the thrombolysis infusion catheter positioned across the occluded segment.

Fig. 5

Repeat angiogram via the existing thrombolysis infusion catheter (not shown) and guiding catheter at 12 hours shows resolution of the thrombus with re-established flow within the coeliac artery. The splenic artery is not opacified and remains occluded.

Fig. 6

An elderly patient presented with massive upper gastrointestinal bleeding. (a) On selective cannulation of the coeliac artery, catheter angiogram shows opacification of the common hepatic artery (white arrowhead), splenic artery (black arrowhead) and gastroduodenal artery (white arrow). The right hepatic artery is not seen. (b) After cannulating the superior mesenteric artery (SMA), catheter angiogram shows a replaced right hepatic artery (black arrow) arising from the proximal SMA.

Fig. 7

A middle-aged man presented with upper abdominal pain and sepsis. Axial CT image shows marked enlargement of the liver and spleen with patchy areas of hypoperfusion, suspicious for hepatic and splenic infarction.