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(Radiology. 2000;214:604-606.)
© RSNA, 2000

Letters to the Editor

Compression of the Celiac Trunk by the Median Arcuate Ligament

Brian Funaki, MD

Department of Radiology, University of Chicago Hospitals MC 2026, 5841 South Maryland Avenue, Chicago, IL 60637

Editor:

I read with interest the article by Dr Lim and associates in the May 1999 issue of Radiology (1) regarding the detection of splanchnic arterial stenoses with Doppler ultrasonography (US). In the authors' series, excellent accuracy was demonstrated, although there was a definite discrepancy between the results of Doppler US and those of lateral abdominal aortography in the detection of celiac trunk and superior mesenteric arterial stenoses.

Specifically, there were nine false-positive diagnoses of celiac trunk stenosis and only one false-positive diagnosis of superior mesenteric arterial stenosis. Dr Lim and colleagues attribute this difference to tortuosity of the celiac trunk. The article does not indicate whether US and angiography were performed during the same phase of respiration, which could have important implications on evaluation of the celiac trunk. The median arcuate ligament is found in 10%–24% of patients (2) and can impinge on the celiac trunk to a variable extent during normal breathing (Figure).



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  		Figure 1a. Variable compression of the celiac trunk during respiration. (a) Lateral digital subtraction aortogram obtained at end expiration shows narrowing (arrow) of the celiac trunk. (b) Lateral aortogram obtained at end inspiration shows no significant narrowing.

 


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  		Figure 1b. Variable compression of the celiac trunk during respiration. (a) Lateral digital subtraction aortogram obtained at end expiration shows narrowing (arrow) of the celiac trunk. (b) Lateral aortogram obtained at end inspiration shows no significant narrowing.

 
While the median arcuate ligament syndrome is controversial, the presence of the ligament and its compression on the celiac trunk are well established (3). US interrogation of the celiac trunk is facilitated in the end of expiration, and this phase of respiration may be even exaggerated by compression of the abdominal wall by the US probe. Therefore, if US was performed at end expiration and angiography was performed at end inspiration, discrepancies between modalities would be expected in a small number of patients. I wonder if this may be in part responsible for the apparent decreased accuracy of US in the detection of celiac trunk stenoses.

References

  1. Lim HK, Lee WJ, Kim SH, et al. Splanchnic arterial stenosis or occlusion: diagnosis at Doppler US. Radiology 1999; 211:405-410.[Abstract/Free Full Text]
  2. Lindner HH, Kemprud E. A clinicoanatomic study of the arcuate ligament of the diaphragm. Arch Surg 1971; 103:600-605.[Abstract/Free Full Text]
  3. Reuter S. Accentuation of celiac compression by the median arcuate ligament of the diaphragm during deep expiration. Radiology 1971; 98:561-564.[Medline]

Dr Lim responds:

Hyo K. Lim, MD

Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, South Korea

My colleagues and I thank Dr Funaki for his interest in our article (1). It is known that the phase of respiration can alter the course of the celiac trunk and affect the peak systolic velocity measured with Doppler US (2). We also found the same phenomenon during the early stage of Doppler US examination of the splanchnic artery. At our institution, abdominal aortography is performed with the patient at full inspiration. We performed all Doppler US examinations during the same phase of respiration to prevent any discrepancy between the two modalities. Therefore, we do not think that the false-positive diagnosis of celiac trunk stenosis in our series resulted from a different phase of respiration.

In obese patients, the celiac trunk—located deep in the abdomen—may be difficult to interrogate with a Doppler sample volume when the patient is at full inspiration. Fortunately, most Asians are thin in body habitus, which enables us to examine the patients at our institution without difficulty, even if they are at full inspiration. The merit of Doppler US examination performed at full inspiration is that the influence of ligamentous compression on the velocity of the celiac trunk is less pronounced in this phase (2).

Although compression of the celiac trunk by the median arcuate ligament is a well-documented anatomic variant and can be seen in 10%–24% of patients (3), severe stenosis of the celiac trunk is reported to be rare (4). In fact, we found severe stenosis of the celiac trunk due to median arcuate ligamentous compression in only one patient over the past 4 years. The patient had no subjective abdominal symptoms except an abdominal bruit at physical examination. Considering the rarity of severe celiac trunk stenosis due to ligamentous compression, we believe that ligamentous compression of the celiac trunk is not a critical problem in performing a Doppler US examination when it is performed at full inspiration.

References

  1. Lim HK, Lee WJ, Kim SH, et al. Splanchnic arterial stenosis or occlusion: diagnosis at Doppler US. Radiology 1999; 211:405-410.
  2. Geelkerken RH, Delahunt TA, Schultze Kool LJ, van Baalen JM, Hermans J, van Bockel JH. Pitfalls in the diagnosis of origin stenosis of the coeliac and superior mesenteric arteries with transabdominal color duplex examination. Ultrasound Med Biol 1996; 22:695-700.[Medline]
  3. Lindner HH, Kemprud E. A clinicoanatomic study of the arcuate ligament of the diaphragm. Arch Surg 1971; 103:600-605.
  4. Pattern RM, Coldwell DM, Ben-Menachem Y. Ligamentous compression of the celiac axis: CT findings in five patients. AJR 1991; 156:1101-1103.[Abstract/Free Full Text]




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