CURRENTWhite RD et al. · RadioGraphics 2015;35(3):879-898
BOTTOM LINE: Before any upper-abdominal embolization or surgical planning, map the celiac branching pattern and variant hepatic supply, and recognize median arcuate ligament compression by its focal, hooked, expiration-worsened narrowing of the PROXIMAL celiac — which separates extrinsic compression from fixed ostial atherosclerosis.
Key points
- Classic celiac trunk = hepatosplenogastric trifurcation (common hepatic, splenic, left gastric); this is the most common configuration, but a sizeable minority have variant hepatic supply.
- Map replaced/accessory hepatic arteries before TACE, GI-bleed embolization, Whipple, or transplant: a replaced right hepatic typically arises from the SMA and a replaced left hepatic from the left gastric artery.
- Median arcuate ligament compression causes focal narrowing of the PROXIMAL celiac with a hooked/J-shaped contour that worsens in expiration and improves in inspiration, distinguishing extrinsic compression from fixed, often calcified ostial atherosclerosis.
- Chronic mesenteric ischemia usually requires significant disease in at least two of the three mesenteric arteries because of the rich pancreaticoduodenal and arc-of-Buhler collateral network between the celiac axis and SMA.
- Other celiac pathology to recognize: isolated celiac dissection, aneurysm/pseudoaneurysm, and a celiacomesenteric trunk, each of which alters endovascular and surgical strategy.
At the workstation
Before any upper-GI or hepatic embolization, dictate the celiac branching pattern and any replaced/accessory hepatic arteries or celiacomesenteric trunk; when you see proximal celiac narrowing, use the contour and respiratory phase to call median arcuate ligament compression versus atherosclerotic stenosis, since this changes catheter strategy and whether surgery is needed.
Board pearl: A focal superior indentation of the proximal celiac artery with a hooked contour that worsens on expiration indicates median arcuate ligament compression, not atherosclerosis (which is ostial, fixed, and often calcified); stenting without ligament release tends to fail.
Findings & methods
Imaging role: CT and MR angiography with multiplanar/3D reconstructions and catheter angiography define the celiac origin, branching pattern, and variant hepatic supply; expiratory-phase imaging is key when median arcuate ligament compression is suspected.
Key variants: The classic hepatosplenogastric trifurcation is most common, but replaced/accessory right hepatic (typically from the SMA) and left hepatic (from the left gastric) arteries are frequent, and a celiacomesenteric trunk is a high-stakes variant before embolization or surgery.
Pathology & management: The celiac axis is affected by atherosclerotic stenosis/occlusion, extrinsic median arcuate ligament compression, dissection, aneurysm/pseudoaneurysm, and vasculitis; MAL compression often needs surgical ligament release rather than stenting alone.
Limitations & caveats
- Pictorial/educational review, not a diagnostic-accuracy trial.
- Median arcuate ligament indentation is frequently seen in asymptomatic people, so imaging must be correlated with clinical symptoms before treatment.
Read the deep dive
The celiac axis is the first major ventral branch of the abdominal aorta and classically trifurcates into the common hepatic, splenic, and left gastric arteries (the hepatosplenogastric pattern). Variant anatomy is frequent and clinically decisive: a replaced or accessory right hepatic artery usually arises from the SMA and courses posterolateral to the portal vein, while a replaced or accessory left hepatic artery arises from the left gastric artery. A celiacomesenteric trunk, in which the celiac axis and SMA share a common origin, is higher-risk because disease or catheter manipulation at that shared origin jeopardizes both mesenteric territories. Mapping these variants before chemoembolization, GI-bleed embolization, pancreaticoduodenectomy, or transplantation prevents non-target embolization and ischemic complications.
Pathologically, the celiac axis is narrowed by intrinsic atherosclerosis or extrinsic compression by the median arcuate ligament. The ligament produces a characteristic focal indentation of the superior aspect of the proximal celiac artery with a hooked, J-shaped contour, post-stenotic dilation, and dynamic worsening on expiration with improvement on inspiration — separating it from the fixed, ostial, frequently calcified narrowing of atherosclerosis. Because of the rich pancreaticoduodenal and arc-of-Buhler collaterals between the celiac and SMA circulations, symptomatic chronic mesenteric ischemia generally requires high-grade disease in at least two of the three mesenteric arteries.