Median arcuate ligament compression of the celiac and superior mesenteric arteries

Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy

BACKGROUND

Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut.

METHODS

All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]).

RESULTS

Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction.

CONCLUSION

Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.

Supradiaphragmatic origin of the celiac trunk leading to median arcuate ligament syndrome with superior mesenteric artery involvement

Median arcuate ligament (MAL) syndrome (MALS) is a rare condition caused by compression of the celiac artery by the MAL. Symptoms include abdominal pain, nausea, and weight loss. Rarely, the MAL can compress both the celiac artery and the superior mesenteric artery (SMA). We describe the case of a young man with MALS involving the celiac artery and SMA. Laparoscopic release of the MAL was performed, and the patient had resolution of his symptoms at 6 months of follow-up. A review of the literature identified only six cases of MALS involving the SMA and celiac artery, making this a rare occurrence.

Preoperative imaging and prediction of oesophageal conduit necrosis after oesophagectomy for cancer

BACKGROUND

Oesophageal conduit necrosis following oesophagectomy is a rare but life-threatening complication. The present study aimed to assess the impact of coeliac axis stenosis on outcomes after oesophagectomy for cancer.

METHODS

The study included consecutive patients who had an Ivor Lewis procedure with curative intent for middle- and lower-third oesophageal cancer at two tertiary referral centres. All patients underwent preoperative multidetector CT with arterial phase to detect coeliac axis stenosis. The coeliac artery was classified as normal, with extrinsic stenosis due to a median arcuate ligament or with intrinsic stenosis caused by atherosclerosis.

RESULTS

Some 481 patients underwent an Ivor Lewis procedure. Of these, ten (2·1 per cent) developed oesophageal conduit necrosis after surgery. Coeliac artery evaluation revealed a completely normal artery in 431 patients (91·5 per cent) in the group without conduit necrosis and in one (10 per cent) with necrosis (P < 0·001). Extrinsic stenosis of the coeliac artery due to a median arcuate ligament was found in two patients (0·4 per cent) without conduit necrosis and five (50 per cent) with necrosis (P < 0·001). Intrinsic stenosis of the coeliac artery was found in 11 (2·3 per cent) and eight (80 per cent) patients respectively (P < 0·001). Eight patients without (1·7 per cent) and five (50 per cent) with conduit necrosis had a single and thin left gastric artery (P < 0·001).

CONCLUSION

This study suggests that oesophageal conduit necrosis after oesophagectomy for cancer may be due to pre-existing coeliac axis stenosis.

Compression of the Superior Mesenteric Artery by the Median Arcuate Ligament: A Cause for Mesenteric Ischemia

Extrinsic compression of the superior mesenteric artery (SMA) by the median arcuate ligament (MAL) is an uncommon entity. The authors report a case of compression of the SMA by the MAL in a patient with celiac artery occlusion and intestinal angina. Arteriography and computerized tomography were suggestive of the diagnosis. Division of the fibrous bands of the MAL extending onto the anterior surface of the SMA relieved the arterial compression, with subsequent resolution of the patient's symptoms.

Compression of the Celiac Artery by the Median Arcuate Ligament: Multidetector Computed Tomography Findings and Characteristics

Purpose

The prevalence of the celiac artery stenosis caused by median arcuate ligament (MAL) compression and its multidetector computed tomography (MDCT) characteristics were evaluated in patients who underwent abdominal MDCT procedures, retrospectively.

Methods

Totally 1121 patients who had abdominal MDCT with arterial phase or MDCT angiography of the abdominal aorta for various indications were analyzed for celiac artery compression by the MAL.

Results

Fifty (ie, 4.6%) patients showed typical MDCT features of MAL compression. Focal narrowing of the proximal celiac artery, a characteristic hooked appearance of the narrowed segment without calcification and atherosclerotic changes were diagnostic. Poststenotic dilatation was detected in 22 (44%) patients with MAL compression. The ratio of the stenosis of the celiac artery was between 35%-50% in 15 patients and 51%-80% in 35 patients. The gastroduodenal artery diameter of these patients was not significantly different from the asymptomatic control group.

Conclusion

MALS is an uncommon entity but it should be kept in mind in the presence of unexplained gastrointestinal symptoms. MDCT is a minimally invasive and plays a dominant role in the diagnosis of MAL compression especially with reformatted and 3-D reconstructed images.

An unusual case of left renal artery compression: a rare type of median arcuate ligament syndrome

Compression from median arcuate ligament was observed during multidetector 64-row computed tomography in a Caucasian 30-year-old female. The patient was referred for examination to exclude anatomical pathologies causing hypertension. The examination demonstrated that left renal artery, which had its origin in the chest (at the level of upper one-third of Th12), was compressed as it passed by median arcuate ligament of the diaphragm. In addition, aortic compression and kinked shape was also revealed.

Uncommon CT imaging of the hepatic falciform artery in patients presenting with very unusual variants of gastrointestinal arteries: report of two cases

The hepatic falciform artery (HFA) may be found in 68% of subjects in post-mortem dissections. It is well known by interventional radiologists who perform selective hepatic angiography. The reason essentially results from the potential supraumbilical skin complications which may produce by the distribution of chemotherapeutic agents through the HFA after transcatheter chemoinfusion or chemoembolization for liver tumors. Nevertheless, the spontaneous visualization of the HFA remains very unusual in current abdominal CT practice. We hereby report the demonstration of a patent HFA during conventional abdominal CT in two patients presenting without liver disease but in which very unusual variants of the gastrointestinal arteries were simultaneously found. The first patient had a common celiomesenteric trunk and the second had a severe compression of both the celiac trunk and superior mesenteric artery by the median arcuate ligament of the diaphragm. We shortly review the literature about these rare variants. We hypothesize that the HFA was spontaneously visible in our patients because of hypertrophy due supplying collateralization.

Multidetector CT of vascular compression syndromes in the abdomen and pelvis

Certain abdominopelvic vascular structures may be compressed by adjacent anatomic structures or may cause compression of adjacent hollow viscera. Such compressions may be asymptomatic; when symptomatic, however, they can lead to a variety of uncommon syndromes in the abdomen and pelvis, including median arcuate ligament syndrome, May-Thurner syndrome, nutcracker syndrome, superior mesenteric artery syndrome, ureteropelvic junction obstruction, ovarian vein syndrome, and other forms of ureteral compression. These syndromes, the pathogenesis of some of which remains controversial, can result in nonspecific symptoms of epigastric or flank pain, weight loss, nausea and vomiting, hematuria, or urinary tract infection. Direct venography or duplex ultrasonography can provide hemodynamic information in cases of vascular compression. However, multidetector computed tomography is particularly useful in that it allows a comprehensive single-study evaluation of the anatomy and resultant morphologic changes. Anatomic findings that can predispose to these syndromes may be encountered in patients who are undergoing imaging for unrelated reasons. However, the diagnosis of these syndromes should not be made on the basis of imaging findings alone. Severely symptomatic patients require treatment, which is generally surgical, although endovascular techniques are increasingly being used to treat venous compressions.

An unusual origin of the celiac trunk and the superior mesenteric artery in the thorax

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1-L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome).

Mesenteric ischemia

This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.

Median Arcuate Ligament Syndrome in a patient with Crohn's disease

INTRODUCTION

The Median Arcuate Ligament Syndrome is a rare condition characterized by postprandial abdominal pain, bowel function disorder and weight loss. We report the first case to our knowledge of Crohn's disease and Median Arcuate Ligament Syndrome.

PRESENTATION OF CASE

The patient was a 33 year-old female with a previous diagnosis of Crohn's disease. Acute postprandial abdominal pain affected the patient every day; she was, therefore, referred to US-Doppler and magnetic resonance angiography of the abdominal vessels and received a diagnosis of Median Arcuate Ligament Syndrome. Consequently, the patient was surgically treated, releasing the vascular compression. After the operation, she reported a complete relief from postprandial pain which was one of her major concerns. Subocclusive symptoms occurred after six months due to the inflammatory reactivation of the terminal ileitis.

DISCUSSION

The diagnosis of Median Arcuate Ligament Syndrome is mainly based on the exclusion of other intestinal disorders but it should be always confirmed using noninvasive tests such as US-Doppler, angio-CT or magnetic resonance angiography.

CONCLUSION

This case demonstrates that the Median Arcuate Ligament Syndrome could be the major cause of symptoms, even in presence of other abdominal disorders.

External Compression of the Superior Mesenteric Artery by the Median Arcuate Ligament

The median arcuate ligament can compress the proximal portion of the celiac artery causing symptoms of chronic mesenteric ischemia. This rare condition typically affects young women and often poses a diagnostic challenge. Compression of the superior mesenteric artery (SMA) in addition to the celiac artery represents an unusual variant of median arcuate ligament syndrome (MALS). We present a case of MALS resulting predominantly from external compression of the SMA. Diagnostic and therapeutic options are discussed.

Acute celiac artery compression syndrome after surgical correction of Scheuermann kyphosis

STUDY DESIGN

A case of acute celiac artery compression syndrome after spinal fusion in a patient with Scheuermann kyphosis is reported.

OBJECTIVE

To describe the unusual complication of acute celiac artery compression after surgical kyphosis correction, to outline diagnostic methods, and to review the pertinent literature.

SUMMARY OF BACKGROUND DATA

Chronic celiac artery compression syndrome is well described, yet there is only 1 reported case of acute celiac artery compression after surgical correction of kyphosis. There have been no previous reports of this complication leading to foregut ischemic necrosis after correction of Scheuermann kyphosis.

METHODS

Case report and literature review.

RESULTS

After an anterior release and posterior spinal fusion for a 106 degrees kyphotic deformity performed under 1 anesthetic, our patient developed a perforated gastric antrum on postoperative day 5, evolving to ischemic necrosis of the stomach, gallbladder, and spleen discovered on postoperative day 7. Abdominal angiography indicated that his celiac artery had been occluded at its origin. After this event, the patient required a prolonged intensive care hospital stay and required a Roux-en-Y gastro-jejeunostomy reconstruction. He is now doing well at 1-year follow-up with independent ambulation and a regular diet.

CONCLUSION

Acute celiac artery compression after surgical kyphosis correction is a rare but potentially serious adverse event. Spinal deformity surgeons and intensivists should be aware of this entity, and should have a high index of suspicion for it if sepsis of unknown origin, an acute abdomen, or elevated liver enzymes are encountered after surgery after correction of a kyphotic deformity.

Celiac artery stenosis/occlusion treated by interventional radiology

Severe stenosis/occlusion of the proximal celiac trunk due to median arcuate ligament compression (MALC), arteriosclerosis, pancreatitis, tumor invasion, and celiac axis agenesis has been reported. However, clinically significant ischemic bowel disease attributable to celiac axis stenosis/occlusion appears to be rare because the superior mesenteric artery (SMA) provides for rich collateral circulation. In patients with celiac axis stenosis/occlusion, the most important and frequently encountered collateral vessels from the SMA are the pancreaticoduodenal arcades. Patients with celiac artery stenosis/occlusion are treated by interventional radiology (IR) via dilation of the pancreaticoduodenal arcade. In patients with dilation of the pancreaticoduodenal arcade on SMA angiograms, IR through this artery may be successful. Here we provide several tips on surmounting these difficulties in IR including transcatheter arterial chemoembolization for hepatocellular carcinoma, an implantable port system for hepatic arterial infusion chemotherapy to treat metastatic liver tumors, coil embolization of pancreaticoduodenal artery aneurysms, and arterial stimulation test with venous sampling for insulinomas.

Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy

BACKGROUND

Celiac artery occlusion occurs in a small percentage of the population. Identifying this is critical in planning for pancreaticoduodenectomy. We reviewed 332 patients treated with pancreaticoduodenectomy, and identified 14 patients with celiac artery occlusion.

METHODS

Between 1988 and 2006, 14 (4%) of 332 patients treated with pancreaticoduodenectomy had median arcuate ligament syndrome with celiac artery occlusion (6 men, 8 women; mean age, 70 y; range, 38-80 y). Patients underwent preoperative imaging with computed tomography (n = 14) and angiography (n = 13).

RESULTS

Patients were diagnosed preoperatively (n = 13) and intraoperatively (n = 1) with celiac artery occlusion. Surgeries included classic pancreaticoduodenectomy (n = 12), pylorus-preserving pancreaticoduodenectomy (n = 1), median arcuate ligament release (n = 10), and vascular reconstructions (n = 4), with no surgical mortalities and postoperative complications in 6 patients (46%).

CONCLUSIONS

We report our experience of median arcuate ligament syndrome with celiac artery occlusion in 4% of our patients treated with pancreaticoduodenectomy. Patients underwent median arcuate ligament release, vascular reconstruction, and/or stenting. Angiography diagnosed celiac artery occlusion and allowed preoperative planning. Pancreatic surgeons must understand the importance of identifying celiac artery occlusion before resection to prevent severe complications.

Dunbar's syndrome and superior mesenteric artery's syndrome: a rare association

Celiac artery compression syndrome (CACS) and superior mesenteric artery syndrome (SMAS) are 2 rare diseases, widely described in literature. Their association has not been specifically investigated; in fact, few cases have been reported. For this reason we reviewed our experience from January 1974 to June 2004. We report 59 patients affected by CACS and 28 by SMAS. Coexistence of both syndromes in 8 patients was observed. These 8 patients were successfully treated with duodenojejunal bypass and decompression of the celiac trunk. In this paper, we analyze the pathogenesis, clinical presentation, diagnosis, and treatment of these syndromes, emphasizing their common aspects. The misdiagnosis of this association may justify in some cases the controversial results reported regarding the surgical treatment of these syndrome.

Anatomical investigation of the esophageal and aortic hiatuses: physiologic, clinical and surgical considerations

Precise knowledge about the anatomical constitution of the diaphragmatic pillars is essential to understand the physiologic, clinical and surgical roles of the esophageal and aortic hiatuses. Because anatomical descriptions found in the literature are dubious, we have decided to investigate this subject. Anatomical dissections and histologic sections of the right and left diaphragmatic pillars (diaphragma crura) from 43 human bodies were analyzed, comprising both non-fixed and fixed specimens. We have described a classification of the diaphragmatic pillars and their muscular branches, forming two basic arrangements (patterns I and II) around the esophageal and aortic hiatuses. Such anatomical and functional relationships between the esophagus and its diaphragmatic hiatus help explain why, during normal inspiration, a hiatal enlargement is observed first but is followed, thereafter, during deep inspiration, by a hiatal narrowing exerted by the contraction of the diaphragmatic pillars. Our results also show that the aortic hiatus does not seem to constitute a rigid ventral tendinous arc around the aorta that could impose any considerable degree of vascular compression, as suggested by other investigators. The present study provides anatomical data useful for a better understanding of gastroesophageal reflux physiology, antireflux surgery and abdominal angina.

Transcatheter arterial chemoembolization for hepatocellular carcinomas in patients with celiac axis occlusion

PURPOSE

To verify the hypothesis that most instances of celiac axis occlusion in patients with hepatocellular carcinoma (HCC) are caused by diaphragmatic compression and, therefore, transcatheter arterial chemoembolization (TACE) can be performed through the compressed lumen of the celiac axis.

MATERIALS AND METHODS

The authors attempted to perform TACE in 36 consecutive patients with HCC and celiac axis occlusion. Spiral computed tomographic (CT) images were available in 26 patients. Initially, catheterization of the hepatic arteries was attempted through the occluded celiac axis. If it failed, catheterization was performed through the pancreaticoduodenal arcades. The causes of celiac axis occlusion were evaluated based on spiral CT and angiographic findings, access routes, technical success rates, and related complications in superselective catheterization of hepatic arteries.

RESULTS

Among the 26 patients who underwent spiral CT, diaphragmatic compression of the celiac axis was demonstrated in 23. Selective catheterization of hepatic arteries was possible through the occluded celiac axis in 23 patients (64%). In nine (25%) of the remaining 13 patients, TACE was performed through the dilated pancreaticoduodenal arcades from the superior mesenteric artery. As a procedure-related complication, celiac axis dissection occurred in one patient (3%).

CONCLUSION

Most patients with celiac axis occlusion had arcuate ligament compression. In TACE, the celiac artery occlusion could be traversed directly and this should be the initial approach.

Embryologic and anatomic basis of esophageal surgery

The embryogenesis, congenital anomalies, and surgical anatomy and applications of the esophagus for benign and malignant processes are detailed in this article. Emphasis is placed on the role of embryology and the anatomy involved in surgical decisions.

Celiac artery compression syndromes

Compression of the visceral arteries can produce true mesenteric ischemia, but the syndrome is rare. The syndrome is caused by unfavorable anatomic relationships at the aortic hiatus among the CA, the SMA, and overlying structures, particularly the diaphragmatic crura. These anatomic relationships, in contrast to the syndrome they sometimes produce, are relatively common, which makes the detection of CA compression only a prerequisite to the diagnosis of the clinical entity. The diagnosis of CA compression syndrome ultimately depends on the relentless elimination of other possible causes for abdominal pain and on the knowledge that this curious syndrome does indeed exist. If properly diagnosed, the CA compression syndrome can be corrected with a safe, relatively simple surgical procedure. Past treatment series reflect too little appreciation for the extensiveness of a true, chronic CA injury. Revascularization of the CA, in addition to release of compression, should therefore be performed with greater frequency in the future. The young patients who are successfully diagnosed and treated for this unusual syndrome are frequently entirely relieved of long-standing, debilitating pain, and, like other patients with chronic mesenteric ischemia, they typically enjoy dramatic improvement in the quality of their lives. Thus, with the prospect of these patients in mind, a clinician should accept the opinion that the syndrome "does not exist" only after careful consideration of the entire literature.

Median arcuate ligament compression syndrome in monozygotic twins

Twin 27-year-old women had symptomatic mesenteric ischemia caused by median arcuate ligament compression. Arteriography demonstrated severe celiac artery stenosis in one twin, celiac artery occlusion in the other, and proximal superior mesenteric artery narrowing with retrograde filling from a meandering mesenteric artery in both. Division of the ligament and direct celiac artery revascularization completely relieved symptoms in both patients. Median arcuate ligament compression of the celiac and superior mesenteric arteries can result in mesenteric ischemia. Documentation of this unusual syndrome in monozygotic twins suggests that the responsible anatomic relationships are congenital.

Would you recognize celiac axis syndrome?

Since its original description, celiac axis syndrome has been a topic of debate. Clinical findings include postprandial abdominal pain, weight loss, and an epigastric bruit. Diagnosis is often made by exclusion and is confirmed by lateral aortography. The role of surgery in treating celiac axis syndrome is controversial.

Coeliac artery compression

Four women with abdominal pain and compression of the coeliac artery by the median arcuate ligament of the diaphragm are described. Pain was relieved in each case by decompression or reconstruction of the coeliac artery. A case in favour of the existence of the coeliac artery compression syndrome is presented.

[Surgical consequences of anomalous arterial blood supply and aneurysms in the epigastric region (authors' translation)]

Abdominal angiography was performed in patients with occlusive disease of the iliofemoral arteries. In 85 of 389 patients, the anomalous arterial blood supply of the upper abdomen was detected accidentally: 81% of the variations were related to the hepatic artery, 19% to the celiac artery. The possible surgical consequences are discussed if these variations are disregarded. Four patients with aneurysms of the visceral arteries (three aneurysms of the hepatic artery, one aneurysm of the superior mesenteric artery) and one patient with a celiac artery compression syndrome were also detected. The latter diseases represent clear indication for operation with high chances of success if treated in time.