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Saiga A, Koizumi J, Osumi K, Ota J, Kubota Y, Wada T, Akutsu A, Watanabe M, Murai S, Masuda M, Uno T. Celiac Artery Dissection and Retroperitoneal Hemorrhage in Median Arcuate Ligament Syndrome Treated With a Stent and Transcatheter Arterial Embolization: Preprocedural 4-Dimensional Computed Tomography Angiography Assessment. Vasc Endovascular Surg 2021; 56:75-79. [PMID: 34293967 DOI: 10.1177/15385744211028738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 61-year-old man presented with retroperitoneal hemorrhage caused by an aneurysm rupture of the pancreaticoduodenal arcade (PDA), and acute celiac artery dissection distal to celiac axis stenosis. Owing to the gradual growth of the false lumen, we planned to deploy a stent to the celiac artery dissection and embolize the PDA aneurysm. Prior to stent placement, we assessed the acute celiac artery dissection distal to the stenosis using four-dimensional computed tomography (CT) angiography through expiration/inspiration/expiration cycle. We diagnosed median arcuate ligament syndrome considering that the celiac axis showed a hooked narrowing at end-expiration, and the compression decreased at end-inspiration. Additionally, the true lumen distal to the stretched axis dilated in the inspiration phase. Therefore, we could advance a catheter into the true lumen during inspiration and successfully deploy a stent. Subsequently, laparoscopic median arcuate ligament release was performed after the stent deployment. A postoperative CT scan showed good patency in the stent, with disappearance of the blood filling the false lumen and with reduced celiac axis stenosis.
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Affiliation(s)
- Atsushi Saiga
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Jun Koizumi
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Koji Osumi
- Department of Surgery, Ogikubo Hospital, Imagawa, Suginami-ku, Tokyo, Japan
| | - Joji Ota
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yoshihiro Kubota
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Takeshi Wada
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Akira Akutsu
- Department of Radiology, 92154Chiba University Hospital, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Shinji Murai
- Department of Surgery, Ogikubo Hospital, Imagawa, Suginami-ku, Tokyo, Japan
| | - Makiko Masuda
- Department of Radiology, Ogikubo Hospital, Imagawa, Suginami-ku, Tokyo, Japan
| | - Takashi Uno
- Department of Diagnostic Radiology and Radiation Oncology, Chiba University Graduate School of Medicine, Inohana, Chuo-ku, Chiba City, Chiba, Japan
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Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome). Ann Diagn Pathol 2021; 52:151732. [PMID: 33798927 DOI: 10.1016/j.anndiagpath.2021.151732] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m2. They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.
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