Embolization of spontaneous retroperitoneal bleeding fed by aneurysmal arc of Bühler: Case report and technical considerations

The arc of Bühler (AOB) is a rare embryonic anastomosis between the celiac artery and the superior mesenteric artery, which may become a crucial collateral pathway in cases of celiac axis stenosis. We report a challenging case of a 70-year-old woman presenting with hemorrhagic shock owing to a bleeding branch of an aneurysmal and highly tortuous AOB, with median arcuate ligament compression of the celiac trunk. Endovascular treatment was performed successfully by selective embolization of the bleeding branch with the sacrifice of the AOB using a Penumbra Occlusion Device and packing coils, preserving celiac-mesenteric circulation via the pancreaticoduodenal arcade. This case highlights the importance of recognizing vascular variants and adapting embolization strategies to complex anatomy in emergency settings, reinforcing the pivotal role of interventional radiology in managing visceral aneurysms and acute abdominal hemorrhage.