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Celiac artery compression syndrome: a radiological finding without clinical symptoms?

V Kazan, W Qu, M Al-Natour, J Abbas and M Nazzal
Vascular published online 7 May 2013
DOI: 10.1177/1708538113478750

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 tempVascular OnlineFirst, published on May 13, 2013 as doi:10.1177/1708538113478750

Vascular, pp. 1–7, 2013

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ISSN: 1708-5381.
DOI: 10.1177/1708538113478750

ORIGINAL ARTICLE

Celiac artery compression syndrome: a radiological finding

without clinical symptoms?
V Kazan, W Qu, M Al-Natour, J Abbas and M Nazzal

The aim of the paper is to determine the incidence of celiac artery compression (CAC) based on computed tomography (CT) scan and
correlate the findings to the clinical presentation of patients presenting for CT scan in a hospital. Abdominal CT scans of patients
were reviewed between September 2010 and November 2010. CAC was diagnosed if the celiac axis appeared to have a hook or
U-shaped appearance with stenosis. The medical records of the patients were reviewed for gastrointestinal symptoms (abdominal
pain, nausea, vomiting, constipation, diarrhea), as well as food fear and weight loss. Patients with CAC had lower incidence of
symptoms compared with those without CAC (42.1 versus 65.3%, P = 0.042). A total of 450 patients were evaluated. In the end, 284
had both complete medical records and CT scans. The mean age for all patients was 51.3 ± 1.2 years. There were 124 men (42.6%)
and 160 (57.4%) women. Nineteen (6.7%) patients had radiological evidence of CAC. CAC is not an uncommon CT finding in patients
presenting for CT scan.

Key words: celiac artery; celiac artery compression syndrome; CTA; extrinsic compression

Introduction Rainer and Jiminez2 published their findings in Boley’s

Vascular Disorders of the Intestine where they found ostial
The celiac artery compression syndrome (CACS), otherwise
stenosis to be the cause of celiac occlusion in 86% of their
known as Dunbar’s syndrome, is a very controversial and
81 patients. Occlusion of the celiac artery may also be a
much debated entity among vascular surgeons. Harjola
consequence of less common factors such as compression
et al. 1 was one of the first to describe such a syndrome and
from an enlarged pancreas (inflammation or tumor), tumor
associate it with the compression of the celiac artery. The
invasion, arterial tear and congenital etiology.3–7 Although
typical features of CACS include postprandial epigastric
the existence of celiac artery compression has been well
pain, food fear resulting in weight loss and epigastric bruit
documented, the causal relationship between CAC and the
among others. While the syndrome is under debate, the
signs and symptoms of CACS remains unclear. We believe
existence of celiac artery compression (CAC) is, for the
that radiological evidence of celiac artery compression does
most part, accepted as a true pathology. CAC is thought to
not necessarily result in the abdominal symptoms of CACS.
be caused by several mechanisms. Extrinsic compression
Our study aims to investigate whether a clear association
is perhaps the most commonly discussed mechanism.
exists between the symptoms of CACS and CAC.
Extrinsic compression may result from the celiac ganglion,
surrounding fibrous tissue or from the median arcuate
ligament (i.e. the median arcuate ligament syndrome).
Methods
Our study was approved by the Institutional Review Board.
Accepted May 8, 2012 During the months of September 2010–November 2010, all
abdominal CT scans performed at the University of Toledo
Department of Surgery, Division of Vascular and Endovascular Surgery, Medical Center were prospectively analyzed along with the
University of Toledo Medical Center, Toledo, OH, USA
patients’ medical records. All patients with CT scans and
This paper was presented: ISVS Congress 9–11 March 2012 in Miami,
FL, USA. Correspondence to: Munier Nazzal University of Toledo
full medical records were included in this study. Patients
Medical Center, 3000 Arlington Ave., Mail Stop 1095, Toledo, OH whose CT scans did not clearly show the celiac trunk or did
43614, USA; e-mail: munier.nazzal@utoledo.edu not have a complete medical record were excluded from the

1
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2 Kazan et al.

Table 1 Patient characteristics Table 2 Incidence of other arterial abnormalities

With celiac Without celiac With celiac Without
compression compression artery celiac artery
Symptoms (n = 19) (n = 265) compression compression
(n = 19) (n = 265)
With Symptoms* 8 (42.1%) 173 (65.3%)
Sex Celiac artery
Men 11 (57.9%) 113 (42.6%) Stenosis 1(5.3%) 13 (4.9%)
Women 8 (42.1%) 152 (57.4%) Calcification 0 (0.0%) 32 (12.1%)
Abdominal pain** 5 (26.3%) 152 (57.4%) Mass effect around artery 0 (0.0%) 0 (0.0%)
Abdominal pain related to meal 1 (5.3%) 12 (4.5%)
Superior mesenteric artery
Nausea 5 (26.3%) 79 (29.8%)
Stenosis 0 (0.0%) 2 (0.8%)
Vomiting 4 (21.1%) 56 (21.1%)
Calcification 3 (15.8%) 49 (18.5%)
Diarrhea 4 (21.1%) 30 (11.3%)
Food fear 0 (0.0%) 3 (1.1%) Inferior mesenteric artery
Weight loss 0 (0.0%) 9 (3.4%) Stenosis 0 (0.0%) 0 (0.0%)
Malnutrition 0 (0.0%) 6 (2.3%) Calcification 1 (5.3%) 15 (5.7%)
Epigastric bruit 0 (0.0%) 1 (0.4%)
Aorta
*P < 0.05; **P < 0.01 Calcification 9 (47.4%) 123 (46.4%)
Aneurysmal 2 (10.5%) 11 (4.2%)

study. The CT scans were performed on a 64 slice Toshiba

Aquillion CT scanner. In cases in which CT contrast was
utilized, patients were given 80 ml of contrast. The patients
were routinely asked to hold their breath at the end of inspi-
ration. Longitudinal and cross-sectional views of the celiac,
superior mesenteric and inferior mesenteric arteries were
analyzed for compression, stenosis and/or calcification. If
the celiac artery had a U-shape or hooked appearance on
CT, it was considered to be compressed.8,9 The cross-
sectional and longitudinal views of the arteries were visually
inspected for areas of narrowing and calcification.
Measurements of arterial diameter were taken at the point
of narrowing and compared with the adjacent normal
segment. Medical records at the time of presentation were
reviewed. Data collection included abdominal pain and its
characteristics, nausea, vomiting, diarrhea, food fear, weight
loss, signs of malnutrition and epigastric bruit. The data
were analyzed with SPSS version 17.
Results
A total of 450 CT scans were reviewed. Only those patients
with full medical records were included in the study.
Ultimately, 284 patients were entered in the study. The
mean age for all patients was 51.3 ± 1.2 years. There were
124 men (42.6%) and 160 (57.4%) women. Patients were
divided into two groups. Group 1 consisted of patients with
evidence of CAC and group 2 included other patients
without CAC. There was no difference between both groups
in age and gender distribution. Out of 284 patients, 19
(6.7%) were found to have radiological evidence of celiac
compression. CAC symptoms were present in 8 (42.1%) of
the patients with celiac compression versus 173 (65.3%) of
those without compression (Table 1). Compression of the
celiac artery occurred in 8 (42.1%) women and 11 (57.9%)
men. Symptoms were reported by 116 (72.5%) women and
65 (52.4%) men. Generally patients with CAC had lower
incidence of symptoms compared with those without CAC
(42.1 versus 65.3%, P = 0.042). Abdominal pain was less fre-
quent in CAC (26.3 versus 57.4%, P = 0.009). All other
symptoms including postprandial pain, nausea/vomiting,
food fear and weight loss were similar between both groups
(Figure 1). In addition, analysis was performed to determine
the number of patients that have 80% stenosis of their celiac
artery. Of the 19 patients with celiac compression of 50% or
more, 2 (10.5%) had a stenosis of at least 80%. Only one of
the two complained of abdominal pain and nausea. By defi-
nition all patients with CAC had celiac artery stenosis sec-
ondary to external compression. One of the CAC patients
in our study had stenosis at the origin of the celiac artery.
The incidence of superior mesenteric artery (SMA) stenosis,
celiac calcification, SMA calcification and aneurysmal dilat-
tion were similar between both groups (Table 2).
Discussion
Celiac artery compression was first described by the anat-
omist Lipshutz in 1917 when he noted structures surround-
ing the celiac artery, such as the median arcuate ligament

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 Celiac artery compression
(MAL), compressing the artery at its origin in cadavers.10 In
1957, Mikkelson11 published a thorough and descriptive
case of intestinal angina. It was not until 1963 that an
association was made between CAC and the symptoms of
CACS by Harjola.1 He reported the case of a 57-year-old
man with epigastric bruit who also experienced postprandial
abdominal pain. The patient’s celiac artery was found to be
compressed by a fibrotic celiac ganglion that was surgically
released and is the first published account in which the
fibrotic celiac ganglion was divided to release the celiac
axis compression. Harjola went on to write several papers
documenting cases of abdominal angina and CAC through-
out the 1960s.12–16 Dunbar et al. 17 at the Ohio State
University reported 15 cases of CAC and abdominal angina.
His descriptive account of CACS and treatment led to the
alternative name of Dunbar’s syndrome. Three years later,
Lord et al. 18 also associated chronic CAC with stenosis.
In the literature, there has been a wide range of inci-
dence reported for CAC. However, a range between 10 and
25%19 appears to most accurately reflect the true incidence
in the general population. In a selected group of patients
presenting to the hospital, a review of CT scans in our
patient population resulted in 6.7% (19 out of 284) inci-
dence of CAC. Women have been reported to have a greater
incidence of CAC than men.8,20 We did not have a signifi-
cant difference in incidence between men and women in
our study population; however, symptoms associated with
CACS were reported by 116 (72.5%) women and 65 (52.4%)
men. Patients without CACS-related signs or symptoms
were found to have a higher incidence of CAC on CT scan
(10.7%) than those with symptoms (4.4%, P = 0.042).
The majority of our patients underwent abdominal CT
(Figures 2 and 3) for evaluation of abdominal symptoms
such as nausea, vomiting, etc. A small number were found
to have renal colic, or were being evaluated for non-related
causes such as renal transplant surgery. The most character-
istic symptoms of CACS (postprandial pain, food fear,
weight loss, malnutrition and abdominal bruit) were found
to exist less frequently compared with the more general
abdominal complaints such as nausea, vomiting and diar-
rhea. As such, the symptomatic patients in this study may
not be comparable with the patients suspected of having
CACS in the literature and may be considered a weakness of
this study. In 1972, Levin et al. 8 sought to study the inci-
dence of CAC in 50 patients free of symptoms that were
randomly selected. These patients underwent abdominal
angiography for reasons not associated with abdominal pain
or gastrointestinal tract symptoms. Two films were taken of
the aorta after dye was injected above the celiac axis and
respiration was held after full expiration. The patients with
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3
more than 50% stenosis were considered to have celiac
artery narrowing. Their patient population consisted of 20
men and 30 women ranging in age from 21 to 77 years. Of
the 50 patients studied, 12 (24%) had a narrowing of their
celiac axis of at least 50%. Only one of 12 had an epigastric
bruit and only three had collateral vessels from the SMA to
the celiac axis. Other authors report similar results.21,22
These results correlate well with our findings and prove that
CAC/narrowing may be more prevalent in the general
population. The presence of CAC does rarely lead to symp-
toms and to the development of CACS.
The association between CAC and clinical symptoms
has been doubted by a number of authors. One of the most
outspoken critics, Szilagyi et al. 19 reviewed 165 surgically
treated cases by a total of 26 various authors. They found
fault in many of these reports as not enough relevant infor-
mation was collected as well as the lack of agreement in
their diagnostic and treatment strategies. Furthermore, they
highlighted the short follow-up periods averaging only 20
months. They reviewed over 200,000 hospital records at
their own institution Henry Ford Hospital in Detroit,
Michigan and could not find one case of CACS that was
properly documented. The researchers also randomly
selected 157 cases and evaluated the patients’ abdominal
arteriograms (performed either by transfemoral catheters or
by translumbar aortography) taken between 1 October 1970
and 30 June 1971. They studied the lateral view of the celiac
artery and determined celiac artery narrowing by measuring
the diameter of the celiac artery at the point of narrowing.
A discussion included in the article among several other
surgeons did include opposing opinions and experiences.
The gold standard for diagnosing CACS, especially by
external compression, continues to be lateral aortic angio-
graphy. CAC appears in lateral aortograms with the artery
having a hooked or U-shaped appearance.8,9 CT angiograms
in combination with three-dimensional (3D) reconstruction
are capable of projecting the same anatomical information
as conventional angiography.23 Multidetector computed
tomography (MDCT) scans with 16 and 64 slices are
capable of providing exact imaging.9 The imaging for our
study utilized 64 slice MDCT scans with the patient’s res-
piration suspended at the end inspiratory phase. Studies
performed in the 1970s24,25 proved that the MAL, celiac
artery and aorta vary in their positions during respiratory
cycle. Compression of the celiac artery is most visible
during expiration. Lee et al. 26 studied a total of 100 patients
undergoing magnetic resonance imaging (MRI) of the
upper abdomen. Patients were divided into two groups con-
sisting of 50 patients each. One group had an MRI taken at
end expiration and the other at end inspiration with venous
4 Kazan et al.
Figure 1 Graph signs and symptoms
phase acquisitions done during the opposite phase of respir-
ation. The radiological studies were reviewed by two blinded
radiologists that were instructed to group the patients
according to the degree of stenosis into five groups (none,
minimal 1–20%, mild 20–40% mild to moderate 40–60%,
moderate 60–80% and severe >80%). In their patient popu-
lation, 55 patients (57%) had a minimum mild artery nar-
rowing at end expiration. Out of the 55 patients, 40 (73%)
had less narrowing at the end of the inspiratory phase while
11 (20%) had no change. The angle of the aorta in patients
found to have mild to severe celiac artery narrowing was
lower (41° ± 19°) than in those classified as having minimal
to no narrowing (50° ± 19°). The authors concluded that it
was best to perform these imaging studies at the end of
inspiration in order to properly identify CAC so as to not
misdiagnose. In 1973, Reuter and Bernstein25 published a
paper in which surgical clips were placed at the free edge of
the MAL of eight patients. The researchers then studied the
movement of these clips during respiration via fluoroscopy.
These studies revealed that the celiac artery, the MAL, as
well as the aorta moved downward during inspiration and
upward in expiration. As a result, the MAL and celiac artery
moved closer together during expiration, thus exaggerating
the degree of CAC. Images taken during suspension
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of breathing at end expiration most accentuates the com-
pression of the celiac artery24 and allows for a clear picture
unhindered by the breathing movements.26 Although
opinions vary, all seem to agree that CAC appears more
clearly at end-expiration. The evidence published by Lee
convincingly favors studying the celiac artery axis at the end
of inspiration. Furthermore, acquiring images at the end of
inspiration will decrease false-positive diagnosis.
Other techniques have also been shown to be useful in
diagnosing CAC such as spiral CT angiography, Doppler
US, selective catheter angiography, MRA,24–26 and gastric
exercise tonometry.23,27,28 Kopecky et al. 29 reported a case
in which spiral CT was used to identify CAC after catheter
angiography failed to reveal it in two of their patients. In
2003, Wolfman et al. 30 published a case report in which
duplex and color flow ultrasound were used to evaluate the
velocities of the celiac arteries during inspiration, expiration
and in the erect position of two patients. Bech31 also greatly
supported the use of duplex ultrasound for realtime
imaging of the celiac axis through the respiratory cycle.
Selective catheter angiography was utilized by Cina and
Safar32 to diagnose CAC in their case report published in
2002. MRI by Lee26 has been detailed in the previous
section. Gastric exercise tonometry was utilized by Otte27
 Celiac artery compression
Figure 2 External compression of the celiac artery as seen on com-
puted tomography (white asterisk)
and Mensink28 to more effectively determine the best
candidates for celiac decompression. In their experience,
stenosis was detected with an accuracy of 86%. Except for
the latter method of diagnosis, radiological tests lack the
ability to correlate the presence of external compression and
its potential of producing the clinical symptoms.
In 1967 Harjola12 published a paper describing the sur-
gical intervention of 13 patients (10 women and 3 men). All
13 patients complained of crampy abdominal pain manifest-
ing between 20 minutes and one hour postprandially and
each were found to have an epigastric bruit upon ausculta-
tion. Stenosis of the celiac artery was verified by aortogra-
phy. Patients were grouped into three main categories
depending on the etiology of the compression. The first cat-
egory had eight patients in whom the celiac ganglion was
constricting the celiac artery. The second group had four
patients with the esophageal hiatus compressing the celiac
axis into a loop. The third and last group consisted of only
one patient that had constriction of the artery by the celiac
ganglion and of the axis by the aortic hiatus. All surgeries
involved surgical release of the celiac artery and/or axis.
Patients were followed up for anywhere between six months
to four years. Of the 13 treated patients, nine remained
asymptomatic throughout the follow-up period, three com-
plained of mild epigastric pain, and one experienced no
improvement at all. Dunbar et al.17 reported their experi-
ence in 1965 surgically treating patients with CAC. Their
patient population consisted of 15 patients found to have
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5
Figure 3 External compression of the celiac axis (indicated by arrow)
CAC after more common causes were ruled out. The article
reported a follow-up of 15 months for one case and a
period of more than nine months for all the other cases.
Out of the 15 patients, 13 were surgically treated to decom-
press the celiac trunk. The 12 women and one man were
reported to have complete alleviation of their abdominal
pain following surgical intervention.
Minimally invasive decompression has been described in
celiac artery decompression. Laparoscopic decompression
of the celiac axis was first published by Roayaie et al. 33 as
a case study in 2000. More recent accounts of minimally
invasive procedures have been published since then.34–37
Roseborough37 published a case series in 2009 in which 15
patients with CAC underwent laparoscopic decompression
of the celiac axis. The patients ranged in age from 20 to
61 years (median age of 40.6 years) and included 13 women
and two men. The procedures were all performed by the
same surgeon. The first procedure mimicked that of a case
report previously published in which the gastroesophageal
junction was mobilized followed by exposure of the aorta
(from the aortic hiatus to the celiac axis) and concluded
with crural repair. Subsequent intervention spared the dis-
section of the aortic hiatus as well as crural repair, thereby
greatly decreasing operative time and preventing the devel-
opment of gastroesophageal reflux. Of the 15 patients, four
were converted to open surgery after unintentional arterial
injury. Patients underwent a thorough work-up in order to
rule out other possible underlying gastrointestinal causes.
6 Kazan et al.
Of the 15 patients treated by laparoscopy, one was
considered to be a clinical failure as his symptoms were
refractory to treatment. Another patient reported an
improvement in symptoms; however, the patient com-
plained of a mild constant pain. Furthermore, additional
stenting of the celiac artery in four of the patients was done
due to their persistent symptoms following the laparoscopic
procedure. Other researchers such as Vaziri et al. 38 have
also reported success in laparoscopic decompression of the
celiac artery. Their group treated three women aged 37, 47
and 49 after extensive work-up ruled out other possible
causes and contrast CT and MRI revealed celiac com-
pression. Following intervention, two of the three women
reported complete alleviation of symptoms while one had
improvement of her symptoms with persistent pain. Duplex
ultrasound of the three women performed within six
months postintervention showed normal velocities in their
celiac arteries. Van Petersen et al. 34 described their novel
retroperitoneal endoscopic technique in 46 of their patients.
Of the 46 patients, 41 experienced resolution or improve-
ment of their symptoms during a median follow-up period
of 20 months.
Conclusion
Celiac artery compression has been a long debated entity. It
has been described in the literature as early as 1917 and
became associated with symptoms in the 1960s. The causal
relationship between compression of the celiac artery axis
and the symptoms which comprise the CACS has been a
controversial topic. Many theories exist as to the underlying
etiology of the gastrointestinal symptoms experienced by
patients found to have compression of the celiac artery.
Various diagnostic modalities have been shown to be
effective in identifying the compression and surgeons have
developed minimally invasive techniques to treat their
patients. Although the existence of celiac artery compression
has been well published in the literature, its existence is
infrequently associated with symptoms. Coexisting abdomi-
nal symptoms usually are not typical for gastrointestinal
ischemia in that weight loss and postprandial pain are
usually absent. Only one research group used a function test
(gastric tonometry) to confirm functional gastrointestinal
impairment. In our study CAC by CT scan was present in
6.7% of patients with little association with clinical symp-
toms indicating that CAC is more of a radiological finding
than a clinical syndrome.
Conflict of interest: none.
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