Hybrid Treatment of Celiac Artery Compression (Median Arcuate Ligament) Syndrome
Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.Digestive Diseases and Sciences (Impact Factor: 2.61). 01/2012; 57(7):1782-5. DOI: 10.1007/s10620-011-2019-x
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ABSTRACT: Introduction: Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed. Methods: Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up. Results: PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment. Conclusion: Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.
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ABSTRACT: Celiac artery compression syndrome is a rare vascular disease, with incidence estimated at 0.4%. However, asymptomatic but hemodynamically significant celiac artery compression is found incidentally in 2.4-8% of the population on examination. The disease is caused by compression of the median arcuate ligament and celiac axis nerve fibers on the celiac artery, usually during expiration, and can cause symptoms of "abdominal claudication". These symptoms include post-prandial epigastric pain, nausea, vomiting, mild weight loss and, less frequently, diarrhea, heartburn, abdominal bloating, constipation, arrhythmias and syncope. Ultrasound, computed tomography (CT), magnetic resonance (MR) and angiography are employed to diagnose celiac artery compression syndrome. Treatment of this disease is based on median arcuate ligament lysis and celiac ganglionectomy either by laparoscopic or open method, with both techniques having similar outcomes.
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