Image in transplantation surgery: median arcuate ligament in liver transplantation

Vandermeulen, Morgan; Moïse, Martin; Meurisse, Nicolas; Honoré, Pierre; Meurisse, Michel; Meunier, Paul; Detry, Olivier

doi:10.1080/00015458.2019.1689649

Cited by 2 publications

(11 citation statements)

References 7 publications

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“…Another finding that is highly suggestive of the presence of MAL is the "hooked" appearance of the celiac artery on sagittal plane reconstructions due to the narrowing of the proximal portion of the celiac artery. 2 There are several reasons that may cause a decreased flow through the HA during a liver transplant. A decrease in flow due to atherosclerosis can be differentiated from MAL by the absence of variation with respiration, especially when there is evidence of aortoiliac atherosclerotic disease.…”

Section: Discussionmentioning

confidence: 99%

“…The majority of the manuscripts used postoperative ultrasound Doppler to assess the adequacy of the hepatic arterial flow after MAL intervention. [1][2][3][7][8][9]11,12,17,[21][22][23][24][25] Fifteen manuscripts note an improvement in the liver function tests, post-MAL intervention. [1][2][3]7,8,11,12,17,[21][22][23][24][25] The rest of the manuscripts did not have any available data.…”

Section: Post-mal Intervention Investigationsmentioning

confidence: 99%

“…[1][2][3][7][8][9]11,12,17,[21][22][23][24][25] Fifteen manuscripts note an improvement in the liver function tests, post-MAL intervention. [1][2][3]7,8,11,12,17,[21][22][23][24][25] The rest of the manuscripts did not have any available data.…”

Section: Post-mal Intervention Investigationsmentioning

confidence: 99%

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Contemporary Management of Median Arcuate Ligament in Liver Transplantation

Babu¹,

Oniscu²

2022

Transplantation Direct

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Liver TransplantationBackground. Median arcuate ligament (MAL) can impair arterial inflow during orthotopic liver transplantation (OLT). Furthermore, approaches to ensure optimal vascular inflow in the presence of MAL is not standardized. Methods. We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL. Results. The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention. Conclusions. We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.

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Section: Discussionmentioning

confidence: 99%

Section: Post-mal Intervention Investigationsmentioning

confidence: 99%

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Contemporary Management of Median Arcuate Ligament in Liver Transplantation

Babu¹,

Oniscu²

2022

Transplantation Direct

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“…Therefore, the diagnosis of MALS is partly clinical and mainly based on radiology. Celiac axis stenosis caused by MAL appears similar to a hook on CECT during sagittal reconstruction[ 28 ]. Abundant collateral branches, post-stenotic dilation and thickening of the MAL can also help in the diagnosis of MALS.…”

Section: Discussionmentioning

confidence: 99%

“…Abundant collateral branches, post-stenotic dilation and thickening of the MAL can also help in the diagnosis of MALS. Angiography used to be a routine test for detecting aberrant arterial vessels but is now used selectively for suspected cases in arterial dynamic studies[ 21 , 28 ]. Gruber et al [ 29 ] found that the combination of a maximum end-expiratory velocity over 350 cm/s in the celiac trunk and a deflection angle higher than 50°, detected using functional ultrasound, was a reliable diagnostic method for MALS.…”

Section: Discussionmentioning

confidence: 99%

Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients

Li¹,

Fan²,

Tian³

et al. 2022

World J Gastrointest Surg

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BACKGROUND In orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce. AIM To evaluate the feasible surgical management of MALS to reduce complications in OLT patients. METHODS Data for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner. RESULTS Eight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory. CONCLUSION The preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.

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Image in transplantation surgery: median arcuate ligament in liver transplantation

Cited by 2 publications

References 7 publications

Contemporary Management of Median Arcuate Ligament in Liver Transplantation

Contemporary Management of Median Arcuate Ligament in Liver Transplantation

Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients

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