Arc of Buhler: A lifesaving anatomic variation. A case report

Abstract

The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

Intravascular Ultrasound-Guided Stenting of the Celiac Artery for Hepatic Hypoperfusion After Acute Type A Aortic Dissection: A Case Report

“…Arterial branch occlusion secondary to aortic dissection, known as malperfusion syndrome, is a major cause of organ ischemia in the setting of type A or B aortic dissection. It affects approximately 30% of patients presenting with type A and 20% of those with a type B dissection [ 10 , 13 , 14 , 15 ]. Celiac artery dissection and stenosis can occur as a complication of aortic dissection, causing fatal end-organ damage if not corrected.…”

“…Postoperative respiratory dysfunction and prolonged mechanical ventilation after TAAD can also lead to liver hypoxia [ 1 ]. While reports involving TAAD are limited, celiac artery occlusion secondary to an extension of type B aortic dissection (TAAB) into the celiac artery has been reported in two case reports [ 5 , 13 ]. Kobayashi et al.…”

“…Nikolaos et al. noted the presence of celiac arterial dissection without end organ malperfusion after using the Arc of Buhler, a variant anastomosis between the superior mesenteric artery and the celiac arterial branches, rendering stent grafting unnecessary [ 13 ].…”

“…Postoperative respiratory dysfunction and prolonged mechanical ventilation after TAAD can also lead to liver hypoxia [1]. While reports involving TAAD are limited, celiac artery occlusion secondary to an extension of type B aortic dissection (TAAB) into the celiac artery has been reported in two case reports [5,13]. Kobayashi et al described the use of two selfexpandable stents (7/40 mm and 10/40 mm) in the celiac artery to successfully restore hepatic function in the setting of TAAB [5].…”

“…Kobayashi et al described the use of two selfexpandable stents (7/40 mm and 10/40 mm) in the celiac artery to successfully restore hepatic function in the setting of TAAB [5]. Nikolaos et al noted the presence of celiac arterial dissection without end organ malperfusion after using the Arc of Buhler, a variant anastomosis between the superior mesenteric artery and the celiac arterial branches, rendering stent grafting unnecessary [13].…”