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:
-
Recognition of CMT on imaging is crucial, especially in recurrent or unexplained mesenteric
ischemia.
-
Even a partial thrombus in a CMT may have significant clinical consequences due to
the lack of collateral pathways.
-
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.
