Hale Ersoy Clinical Gastroenterology and Hepatology

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The Role of Noninvasive Vascular Imaging in Splanchnic and Mesenteric Pathology Hale Ersoy Clinical Gastroenterology and Hepatology Volume 7, Issue 3, Pages 270-278 (March 2009) DOI: 10.1016/j.cgh.2008.12.011 Copyright © 2009 AGA Institute Terms and Conditions

Figure 1 A 44-year-old woman with history of lymphoma and splenectomy presented with abdominal pain. (A) Precontrast CT study demonstrates hyperdensity within the right portal vein suggestive of acute thrombosis (arrow). (B) Axial post-contrast T1-weighted and fat-suppressed equilibrium phase MR image confirms the filling defect within the portal vein (arrow) as well as the splenic vein (arrowhead). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 2 A 46-year-old woman, preoperative CTA study for potential liver donor. Scans were acquired with 64-slice MDCT at 100 kV and 120 mA. Coronal 3D MIP reconstruction demonstrates normal anatomic pattern of the splanchnic and mesenteric arteries. The arch of Riolan connecting the inferior mesenteric artery and middle colic branch of the SMA is also visualized (arrow). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 3 A 66-year-old woman with arteriolosclerosis and end-stage renal failure on dialysis. A CTA study was obtained to determine the patency of the pelvic vessels for kidney transplantation. Axial CT images were acquired during breath hold in inspiration. Sagittal MIP reconstruction demonstrates the diaphragmatic crura causing wedge-shape indentation (white arrow) to the cranial aspect of the celiac trunk (median arcuate ligament syndrome) and associated moderate (50%–70%) diameter stenosis of the celiac trunk, compared with the normal proximal vessel segment. SMA is widely patent (open black arrow). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 4 CTA of an 84-year-old woman with a history of atrial fibrillation presented to the emergency department with severe abdominal pain and vomiting. Sagittal MIP image shows near complete thrombosis of the celiac trunk and the proximal segment of the SMA (arrows). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 5 A 67-year-old man with long history of hypertension. Two-station 3D Gd-MRA of the thoracic and abdominal aorta shows a type B aortic dissection. Entry site is just below the orifice of the left subclavian artery (white arrow). Reentry site is the left common iliac artery origin (open arrow). Dissection flap (black arrows) separates true and false lumens. True lumen (*) is identified on the basis of its continuation with the aortic arch, higher intensity on arterial phase images, and the absence of thrombus. Both the celiac trunk and the SMA originate from the true lumen. Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 6 A 44-year-old man with a diagnosis of Ehlers-Danlos syndrome presented to emergency department with chest pain radiating down to the abdomen. (A) CTA shows dissection of the celiac trunk and partial thrombus within the false lumen (arrow). Note the wedge-shaped perfusion defect in the spleen (*). (B) Elective CA for peripheral vascular evaluation confirms the evidence of celiac trunk dissection as well as splenic and common hepatic artery involvement seen as a lucent line in the contrast within the artery (open arrows). (C) Coronal and (D) axial MIP images obtained from the follow-up 3D Gd-MRA also successfully demonstrate the extension of the dissection into common hepatic (curved arrow) and splenic arteries (straight arrow). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 7 An 83-year-old woman with a long history of portal hypertension and splenomegaly. Axial MIP image of CTA shows multiple aneurysms of the splenic artery with focal wall calcifications. Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 8 A 57-year-old man with a history of alcohol abuse and chronic pancreatitis presented with acute abdominal pain and fever. (A) Axial arterial phase CTA image demonstrates a pseudoaneurysm of gastroduodenal artery (arrow). Note the slow filling of the partially thrombosed portion of the pseudoaneurysm (*). (B) CA shows the saccular pseudoaneurysm with a narrow neck (open arrow). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 9 An 82-year-old woman with a history of hypertension and carotid artery stenosis was admitted to the hospital for work-up of recurrent transient ischemic attack-like symptoms, abdominal pain, and elevated blood lactate levels. Carotid MRA is diagnostic as well. The 3D MIP image of 3D Gd-MRA demonstrates characteristic string-of-beads appearance of fibromuscular dysplasia in the right renal artery (*) and SMA branches (arrows). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 10 A 70-year-old woman with atrial fibrillation on Coumadin therapy admitted to the emergency department. Physical examination revealed red blood per rectum. Mesenteric CTA was obtained. (A) Arterial phase image shows hyperdense material (white arrow) within the jejunum lumen. (B) Late venous phase axial CT image demonstrates increased amount of hyperdense material, which was predictive of active contrast extravasation into the jejunum lumen. (C) Selective SMA catheterization confirms the evidence of active gastrointestinal hemorrhage in the proximal jejunum (black arrow). Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 11 Simultaneous demonstration of hepatic, portal, splenic, and mesenteric veins with MR venogram on a 66-year-old man. Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions

Figure 12 A 38-year-old woman with history of multiple aortic surgeries and cardiac arrhythmia underwent follow-up CTA study for splenic artery aneurysm and chronic occlusion of the splenic and portal veins. Axial MIP image of portal venous phase shows large venous shunts (arrows) between the SMV and the inferior vena cava (IVC) and SMV and the left renal vein (RV). Note the inhomogenous and delayed parenchymal enhancement of the liver (*) on the arteriovenous phase. Clinical Gastroenterology and Hepatology 2009 7, 270-278DOI: (10.1016/j.cgh.2008.12.011) Copyright © 2009 AGA Institute Terms and Conditions