Combined Treatment of Multiple Splanchnic Artery Aneurysms Secondary to Median Arcuate Ligament Syndrome: A Case Study and Review of the Literature

Characteristics and Trends in Median Arcuate Ligament Syndrome (MALS) Associated Visceral Artery Aneurysms: A Systematic Descriptive Review of the Literature

Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P = .84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P = .02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study

PURPOSE

To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables.

METHODS

Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software.

RESULTS

Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values.

CONCLUSION

This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

Recurrent aneurysmatic bleeding of pancreaticoduodenal aneurysm due to median arcuate ligament syndrome: a case report

Median arcuate ligament syndrome (MALS) involves coeliac artery compression, causing a range of symptoms from chronic pain to life-threatening complications. This case features a 52-year-old patient with recurrent retroperitoneal bleeding from MALS-related inferior pancreaticoduodenal artery aneurysms (PDAAs). Emergency interventions, including surgical bleeding control, angioplasty, percutaneous drainage, and median arcuate ligament release, were conducted. The case highlights challenges in diagnosing and managing MALS-related PDAA, emphasizing the importance of early identification and tailored interventions based on clinical symptoms and imaging. Surgical intervention to release the ligament is the primary treatment, with considerations for prophylactic intervention in PDAA cases. Lack of established PDAA management protocols underscores the need for prompt intervention to prevent complications. In conclusion, this report stresses the association between MALS and PDAA, advocating for early identification and tailored management to mitigate complications.

Endovascular treatment of chronic mesenteric ischaemia secondary to a superior mesenteric artery pseudoaneurysm: a modified neurointerventional technique

A man in his late 60s presented with intermittent abdominal pain, nausea, vomiting and approximately 40 pounds of weight loss over the course of a year, most concerning for chronic mesenteric ischaemia. Given a prior negative workup, a CT angiogram was performed and revealed a wide neck mid-superior mesenteric artery pseudoaneurysm (PSA). As PSAs are susceptible to thrombus formation and distal emboli, this incidental finding was considered a possible explanation for his intermittent symptoms and thus required treatment. Anatomical constraints precluded traditional coiling or covered stent placement, so the interventional radiology team used a neurointerventional technique and performed a successful balloon-assisted coil embolisation of the PSA with subsequent resolution of the patient's symptoms. More than 3 years postprocedure, the patient remains asymptomatic with no complications.

Rapid Formation and Hybrid Treatment of a Large Superior Mesenteric Artery Aneurysm

BACKGROUND Superior mesenteric artery (SMA) aneurysms account for about 5.5% of all visceral aneurysms, and are most commonly secondary to infectious causes or dissection. They tend to expand and rupture. Here, we present our successful diagnosis and treatment of a 41-year-old man with asymptomatic coeliac trunk stenosis, in whom the large aneurysm of the branch of the SMA developed in a very short time after conservative treatment of plastron appendicitis. CASE REPORT A 41-year-old man was diagnosed with plastron appendicitis during abdomen ultrasound (US) examination. Following 2 weeks of conservative treatment with intravenous antibiotic therapy, complete resolution of symptoms was obtained and confirmed in the computed tomography (CT) scan, and no other pathologies were diagnosed. Three weeks later, during the US examination, a 33-mm aneurysm of the branch of the SMA was diagnosed. The patient was admitted to the Vascular Surgery Department, where a critical stenosis of the coeliac trunk secondary to the compression by median arcuate ligament and a 33-mm true visceral aneurysm of one of the branches of the SMA were diagnosed. Successful treatment of the aneurysm was performed. Surgical decompression of the coeliac trunk and subsequent elective endovascular embolization of the SMA aneurysm with angioplasty of the coeliac trunk were performed. The postoperative period was uneventful and the patient was released from the hospital and remains asymptomatic. CONCLUSIONS Visceral artery aneurysm can form very quickly. In some of the aneurysms, a combination of open surgical and endovascular methods should be performed.

Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization

PURPOSE

To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization.

METHODS

Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis.

RESULTS

MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases.

CONCLUSIONS

In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.