Normalization of Flow in the Common Hepatic Artery after Decompression of Median Arcuate Ligament Syndrome with Diminution of a Pancreatoduodenal Arcade Aneurysm

Abstract

Median arcuate ligament syndrome (MALS) is caused by constriction of the celiac artery (CA) by the median arcuate ligament of the diaphragm. Ligament release improves perfusion of the CA, resulting in resolution of abdominal symptoms. A 51-year-old female had postprandial abdominal pain for 10 years and underwent computed tomography (CT) scan showing severe stenosis of the CA with pancreatoduodenal arcade aneurysm formation. MALS was diagnosed, and open median arcuate ligament incision was performed to decompress the CA. Intraoperative ultrasonography showed bidirectional turbulent flow in the common hepatic artery (CHA). The median arcuate ligament was uneventfully incised, and compression of the CA released. The perfusion in the CHA was changed to an antegrade direction, and the flow increased. Seven days after the laparotomy, the patient was discharged uneventfully. Follow-up CT scan 20 days after operation showed a diminished pancreatoduodenal arcade aneurysm and inferior pancreatoduodenal artery. Epigastric pain and postprandial distress symptoms were improved. In conclusion, perfusion of the CHA became normalized after median arcuate ligament release. Surgical intervention for MALS not only improved blood flow in the tributaries but also diminished the pancreatoduodenal arcade aneurysm.

Simultaneous laparoscopic treatment of median arcuate ligament syndrome and segmental adenomyomatosis of the gallbladder: A case report

“…In MALS, the superior mesenteric artery “steals” blood flow from the common hepatic artery resulting in visceral ischemia (the “steal” phenomenon) that is aggravated post-prandially. Reversal of the direction of flow in the common hepatic artery may result in a pancreatoduodenal arcade aneurysm due to elevated intravascular pressure [7] . The probability of rupture is much higher for a pancreaticoduodenal arcade aneurysm than for other aneurysms because a pancreaticoduodenal arcade aneurysm tends to rupture regardless of size.…”

Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

“…One manifestation of this complication can be a spectrum of coagulopathies or vasculopathies, mainly affecting the organs supplied by the celiac trunk. For instance, a patient with symptomatology consistent with chronic mesenteric ischemia, along with splenic infarcts or pancreaticoduodenal aneurysms, superior mesenteric artery (SMA) thrombus, and retroperitoneal hemorrhage, should raise a question about examining the vasculature of the area for other abnormalities, to reach a definite diagnosis, which could include MALS, and also, treat the accompanying disease either via surgery or via interventional radiologic methods[ 11 - 15 ]. All these complications and clinical presentations from MALS are reported in the literature, and as the cases of MALS increase, more complications could be associated with it.…”