Recognizing the Celiomesenteric Trunk in Mesenteric Ischemia: Lessons From a Recurrent Case

We would like to share our insights regarding a clinically impactful case of recurrent mesenteric ischemia in the setting of a rare vascular anomaly, the common celiomesenteric trunk (CMT), highlighting its implications in diagnosis and management.

A 58-year-old male presented with dull, persistent abdominal pain for 2 months, which acutely worsened over 4 to 5 days. Notably, he had undergone emergency exploratory laparotomy 5 months earlier for acute distal ileal ischemia due to thrombosis of a distal ileal branch of SMA, necessitating resection of 105 cm of ileum and a side-to-side anastomosis. At that time, CT angiography (CTA) revealed a common CMT with a partial eccentric thrombus near its origin (20–30% luminal narrowing), characterized by irregular margins and a free-floating edge.

Despite initial recovery, the patient had recently discontinued oral antithrombotics 20 days prior to re-presentation. On examination, left hypochondrial tenderness was noted. CTA during current admission showed residual eccentric thrombus in the proximal SMA, now extending into the first three jejunal branches, with associated proximal jejunal ischemia not seen on prior imaging. Emergency laparotomy confirmed ischemic bowel, and 15 cm of proximal jejunum was resected with a new side-to-side anastomosis ([Fig. 1]). Comparative imaging with previous CT scan ([Fig. 2]) revealed smooth margin resolution of the prior CMT thrombus (now 10–20% occlusion) and no visible collateralization between the CMT and inferior mesenteric artery.

Fig. 1 Multiplanar reformatted images of CECT abdomen in arterial phase, (A) coronal maximum intensity projection image and (B, C, D) sequential axial images, show eccentric thrombus along the proximal SMA extending into the first three jejunal branches (blue arrow in A, red arrows in B, C, D). Axial and coronal CECT images in venous phase (E, F) show changes of bowel and mesenteric ischemia in the proximal jejunum (yellow arrows in E, F). (G) Coronal CECT image shows anastomotic site from previous surgery (green arrow). (H) Intra-operative image shows congested, faecal-stained bowel, suggesting gangrenous bowel. Resection of 15 cm of this gangrenous proximal jejunum was done.

Fig. 2 (A) Coronal maximum intensity projection (MIP) image of previous CECT abdomen (arterial phase) show celiomesenteric trunk with eccentric thrombus along the inferior margin with free-floating edge (yellow arrow). (B) Coronal MIP image of the current CECT abdomen (arterial phase) shows the same eccentric thrombus with smooth margins (yellow arrow) and eccentric thrombus in the proximal thrombus (red arrow). (C) Axial image of previous CECT abdomen (arterial phase) shows the free-floating edge of the thrombus. (D) Coronal reformatted MIP image of previous CECT abdomen (arterial phase) shows normally opacified jejunal branches (blue arrow) and non-opacification of the distal ileal branch (green arrow). (E, F) Coronal and axial CECT images of previous scan (venous phase) shows changes of bowel and mesenteric ischemia in distal ileal loops. Resection of 105cm of gangrenous distal ileum was done during previous surgery.

Laboratory work-up revealed normal coagulation parameters, normal Protein C and S levels, but mildly elevated homocysteine levels (30 μmol/L). The atherosclerotic burden was confined to the CMT, with the abdominal aorta and other branches spared. Given the chronicity and stability of the residual CMT thrombus, no endovascular intervention was pursued. The patient was discharged on optimized anticoagulation with dietary advice and homocysteine-lowering therapy.

Embryologically, the CMT arises due to failed cleavage between the third and fourth aortic roots, resulting in a common origin of the celiac and SMA trunks, a variant seen in only 0.5 to 2.7% of individuals.[1] [2] While often incidental, CMT variants lack robust collateral supply, making any thrombotic or stenotic event clinically catastrophic.[3] The absence of collateral flow in our case likely contributed to recurrent ischemia despite localized thrombus.

CTA played a pivotal role in diagnosis and surgical planning. High-resolution MIP and axial reconstructions were essential in tracing the extent of thrombus, identifying ischemic segments, and evaluating the evolution of the prior lesion. Literature supports CTA as the gold standard for evaluating mesenteric arterial variants and related pathology.[4]

This case underscores three key clinical insights:

1. Recognition of CMT on imaging is crucial, especially in recurrent or unexplained mesenteric ischemia.

2. Even a partial thrombus in a CMT may have significant clinical consequences due to the lack of collateral pathways.

3. Multidisciplinary management, including vascular and gastrointestinal surgical input, is essential in guiding treatment strategy and long-term care.

We advocate for increased radiologic awareness and structured reporting of mesenteric arterial variants, particularly in the setting of abdominal pain with vascular risk factors. Early recognition may improve outcomes through timely surgical or endovascular intervention.

Teaching point: the CMT is a rare vascular variant that poses a unique risk for mesenteric ischemia due to compromised collateral circulation. CTA enables accurate diagnosis, while recognition of this anomaly is crucial for guiding acute and preventive care strategies.

Patient Consent

Written informed consent for participation and publication was obtained from the patient.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Authors' Contributions

Conception and study design: Siddhi C. and Sanjay C. Literature review: Siddhi C. and P.C. Drafting of the manuscript: Siddhi C. and S.R.S.D. Critical revision: M.B., Siddhi C., and M.S.R.

Publikationsverlauf

Artikel online veröffentlicht:
25. September 2025

• References

• 1 Ratra A, Campbell S. Recurrent mesenteric ischemia from celiomesenteric trunk stenosis. Cureus 2018; 10 (06) e2751
• 2 Lovisetto F, Finocchiaro De Lorenzi G, Stancampiano P. et al. Thrombosis of celiacomesenteric trunk: report of a case. World J Gastroenterol 2012; 18 (29) 3917-3920
• 3 Peterson J, Hage AN, Diljak S. et al. Incidental anatomic finding of celiacomesenteric trunk associated with ‘nutcracker phenomenon,’ or compression of the left renal vein. Am J Case Rep 2017; 18: 1334-1342
• 4 Rangankar V, Kapoor R, Kumar D. et al. Spontaneous dissection of celiacomesenteric trunk with isolated extension and thrombosis in the superior mesenteric artery: a case report and literature review. Egypt J Radiol Nucl Med 2024; 55: 32