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Jalili J, Javadrashid R, Alvandfar D, Falahatian M, Jafarizadeh A, Alihosseini S, Hashemizadeh SE. Obstructive jaundice as a rare complication of multiple pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: a case report and review of the literature. J Med Case Rep 2023; 17:385. [PMID: 37689729 PMCID: PMC10493028 DOI: 10.1186/s13256-023-04114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 08/03/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Obstructive jaundice has various causes, and one of the rarest is pancreaticoduodenal artery aneurysm (PDAA), which is often associated with celiac axis stenosis caused by median arcuate ligament syndrome (MALS). CASE PRESENTATION The patient was a 77-year-old Azeri woman who presented with progressive jaundice, vague abdominal pain, and abdominal distension from 6 months ago. The intra- and extrahepatic bile ducts were dilated, the liver's margin was slightly irregular, and the echogenicity of the liver was mildly heterogeneous in the initial ultrasound exam. A huge cystic mass with peripheral calcification and compressive effect on the common bile duct (CBD) was also seen near the pancreatic head, which was connected to the superior mesenteric artery (SMA) and had internal turbulent blood flow on color Doppler ultrasound. According to the computed tomography angiography (CTA) findings, the huge mass of the pancreatic head was diagnosed as a true aneurysm of the pancreaticoduodenal artery caused by MALS. Two similar smaller aneurysms were also present at the huge aneurysm's superior margin. Due to impending rupture signs in the huge aneurysm, the severe compression effect of this aneurysm on CBD, and the patient's family will surgery was chosen for the patient to resect the aneurysms, but unfortunately, the patient died on the first day after the operation due to hemorrhagic shock. CONCLUSION In unexpected obstructive jaundice due to a mass with vascular origin in the head of the pancreas, PDAA should be considered, and celiac trunk should be evaluated because the main reason for PDAA is celiac trunk stenosis or occlusion by atherosclerosis or MALS. The treatment method chosen (including transarterial embolization, open surgery, or combined method) depends on the patient's clinical status and radiological findings, but transarterial embolization would be safer and should be used as a first-line method.
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Affiliation(s)
- Javad Jalili
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Radiology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Javadrashid
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Radiology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Dara Alvandfar
- Department of General Surgery, Emam Reza Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masih Falahatian
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Ali Jafarizadeh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samin Alihosseini
- Medical Radiation Sciences Research Group, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyedeh Elnaz Hashemizadeh
- Department of Surgical and Clinical Pathology, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Tanitame K. Pancreaticoduodenal Artery Aneurysm due to Median Arcuate Ligament Compression of the Celiac Artery. Chonnam Med J 2023; 59:200-201. [PMID: 37840683 PMCID: PMC10570860 DOI: 10.4068/cmj.2023.59.3.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 10/17/2023] Open
Affiliation(s)
- Keizo Tanitame
- Department of Diagnostic Radiology, Araki Neurosurgical Hospital, Hiroshima, Japan
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Schneider M, Longchamp J, Uldry E, Corpataux JM, Kefleyesus A, Halkic N. Systematic hybrid laparoscopic and endovascular treatment of median arcuate ligament syndrome: A single-center experience. Front Surg 2023; 10:1169681. [PMID: 37151859 PMCID: PMC10154560 DOI: 10.3389/fsurg.2023.1169681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/23/2023] [Indexed: 05/09/2023] Open
Abstract
Background Median arcuate ligament syndrome (MALS) is caused by celiac trunk (CT) compression by the median arcuate ligament. Clinically, this pathology varies from postprandial pain (Dunbar syndrome) to a life-threatening hemorrhage because of a rupture of a gastroduodenal artery aneurysm (GAA). Due to the low prevalence of this disease, there is no standard management for MALS. Material and method This was a single-center, retrospective study of 13 patients. Two groups were identified on the basis of the initial clinical presentation: those operated for a GAA rupture (bleeding group-BG) and those operated electively for Dunbar syndrome (Dunbar syndrome group-DG). The primary endpoint was 30-day postoperative complications of a systematic laparoscopic release of the median arcuate ligament and stenting during the same procedure. Results Seven patients (54%) underwent elective surgery. Six patients (46%) underwent semiurgent repair under elective conditions post-embolization for GAA bleeding. The total operative time was longer in the BG (p = 0.06). Two patients in the BG suffered early major complications and needed reintervention, and those in the DG had a lower comprehensive complication index. No mortality was reported at 30 days. Overall median length of stay was 5 days (IQR: 3.5-15.3). Patients in the DG had a significantly shorter length of stay (p = 0.02). At 6 months, the primary and secondary CT stent patencies were 82% and 100%, respectively. There were no high-flow GAA recurrences. Conclusions A combined approach of laparoscopic release of the median arcuate ligament and stenting during the same procedure is feasible and safe, and this approach must be systematically discussed in symptomatic patients.
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Affiliation(s)
- Michael Schneider
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Correspondence: Michael Schneider
| | - Justine Longchamp
- Department of Vascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Onishi Y, Shimizu H, Isoda H, Shinozuka K, Ohtsuru S, Nakamoto Y. Transcatheter arterial embolization for bleeding from the pancreaticoduodenal artery in patients with celiac artery stenosis: A technical report. Acta Radiol Open 2022; 11:20584601221135180. [PMID: 36313861 PMCID: PMC9597204 DOI: 10.1177/20584601221135180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/09/2022] [Indexed: 11/12/2022] Open
Abstract
Background Transcatheter arterial embolization (TAE) is widely accepted as a treatment for bleeding from the pancreaticodoudenal artery (PDA) in patients with celiac artery stenosis. However, the technical aspect of TAE has not received much attention. Purpose To report the technical details and success rate of TAE for bleeding from the PDA in patients with CA stenosis. Material and Methods Between 2015 and 2021, nine TAE procedures were performed in eight patients (five women, three men; one woman underwent TAE twice). The cause of CA stenosis was compression by the median arcuate ligament in eight cases and CA dissection in one case. The cause of bleeding was flow-related aneurysm rupture in six cases. Pre-TAE CT showed a pseudoaneurysm in all cases. The technical details of TAE were recorded, and the success rate was evaluated. Results The technical and clinical success rates were 100%. In six cases, both the CA and superior mesenteric artery (SMA) were cannulated using two parent catheters: a microcatheter advancing to the pseudoaneurysm from the CA (the CA approach) to achieve embolization and another catheter for angiography advancing from the SMA to map the vascular anatomy. In five cases, the CA approach was successfully performed after failed attempts of advancing a microcatheter from the SMA. Conclusion TAE is an effective treatment for bleeding from the PDA in patients with CA stenosis. Using two parent catheters, one for CA cannulation and microcatheter advancement and another for SMA cannulation and vascular mapping, may be a useful technique.
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Affiliation(s)
- Yasuyuki Onishi
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan,Yasuyuki Onishi, MD, Department of
Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto
University, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Hironori Shimizu
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Hiroyoshi Isoda
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Ken Shinozuka
- Department of Primary Care and
Emergency Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and
Emergency Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
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Lu XC, Pei JG, Xie GH, Li YY, Han HM. Median arcuate ligament syndrome with retroperitoneal haemorrhage: A case report. World J Clin Cases 2022; 10:7509-7516. [PMID: 36158028 PMCID: PMC9353894 DOI: 10.12998/wjcc.v10.i21.7509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is relatively rare and is due to extraluminal compression of the coeliac artery by the median arcuate ligament of the diaphragm. Here, we report a case of MALS found in a patient with abdominal pain and retroperitoneal haemorrhage for education and dissemination.
CASE SUMMARY This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.
CONCLUSION MALS is very rare and usually has postprandial abdominal pain, upper abdominal murmur, and weight loss. It is diagnosed by imaging or due to complications. When a patient has abdominal bleeding or PDAA, we should consider whether the patient has celiac trunk stenosis (MALS or other etiology). When abdominal bleeding is combined with an aneurysm, we generally think of aneurysm rupture and hemorrhage first, but it may also be collateral artery rupture and hemorrhage.
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Affiliation(s)
- Xiao-Chen Lu
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Jian-Guo Pei
- Department of Imaging, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Hua Xie
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Yong-Yu Li
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Hong-Mei Han
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
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Uchiyama H, Kuma S, Ishida M, Tsujita E, Nobuto Y, Kasagi Y, Natsugoe K, Aoyagi T, Iguchi T, Itoh H. Resection and reconstruction of pancreatic artery aneurysms caused by the compression of the celiac trunk by the median arcuate ligament: a report of two cases. Surg Case Rep 2021; 7:167. [PMID: 34268612 PMCID: PMC8282884 DOI: 10.1186/s40792-021-01247-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Some patients with the compression of the celiac trunk by the median arcuate ligament (MAL) suffer pancreatic artery aneurysms (PAAs) due to excessive blood flow from the superior mesenteric artery. These aneurysms are in peril because they are prone to rupture irrespective of size. Here, we present two cases of resection and reconstruction of PAAs caused by the compression of the celiac trunk by the MAL.
Case presentation Patient 1 was a 44-year-old man who was first diagnosed to have a visceral artery aneurysm with a diameter of 4 cm accidentally found by ultrasound examination at a regular medical check-up. Contrast-enhanced CT revealed the compression of the celiac trunk by the MAL and a PAA originating from the first jejunal artery. First, laparoscopic excision of the MAL followed by a stent placement into the celiac trunk was performed. Although the stent was patent, the PAA still grew. The patient underwent resection and reconstruction of the PAA. Reconstruction of the pancreatic arterial arcade was needed because clamping of the inferior pancreaticoduodenal artery (IPDA) resulted in disappearance of the hepatic arterial blood flow. The follow-up CT 2 years and 9 months after the operation revealed no recurrence of aneurysms and the patent anastomosis. Patient 2 was a 68-year-old man who presented with an epigastric pain. Contrast-enhanced CT revealed the compression of the celiac trunk by the MAL and a PAA approximately 6 cm in diameter originating from the IPDA. The PAA was surrounded by a relatively low-intensity area, suggesting impending rupture of the PAA. The patient underwent resection and reconstruction of the PAA under an emergency situation. Reconstruction of the pancreatic arterial arcade was needed because clamping of the inflow IPDA resulted in disappearance of the hepatic blood flow. The follow-up CT 1 year and 8 months after the operation revealed no recurrence of aneurysms and the patent anastomosis. Conclusions Although long-term follow-up is needed, resection and reconstruction is one of the therapeutic choices for PAAs caused by the compression of the celiac trunk by the MAL in order to prevent catastrophic aneurysm rupture.
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Affiliation(s)
- Hideaki Uchiyama
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan.
| | - Sosei Kuma
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Mayumi Ishida
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Eiji Tsujita
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Yoshinari Nobuto
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Yuta Kasagi
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Keita Natsugoe
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Takehiko Aoyagi
- Department of Surgery, National Hospital Organization Fukuokahigashi Medical Center, Koga, 811-3195, Japan
| | - Tomohiro Iguchi
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, 810-0001, Japan
| | - Hiroyuki Itoh
- Department of Surgery, Saiseikai Fukuoka General Hospital, Fukuoka, 810-0001, Japan
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