Treatment of Median Arcuate Ligament Syndrome in Young Patients at a Community Hospital
Kathryn Capasso, MD, Nadia Awad, MD, Evan Deutsch, MD, Aaron Ilano, MD, Rashad Choudry, MD.
Einstein Healthcare Network, Philadelphia, PA, USA.
OBJECTIVES: Median arcuate ligament syndrome (MALS) is characterized by compression of the celiac artery, causing chronic abdominal pain, weight loss, nausea, and diarrhea. Surgical treatment includes release of the median arcuate ligament (MAL) followed by either percutaneous or open surgical repair of a persistent celiac artery stenosis. METHODS: We present two cases of MALS in young patients at a community hospital to illustrate the effectiveness of different treatment modalities in a treatment algorithm. RESULTS: A 20-year old female presented to the office for evaluation of persistent abdominal pain, nausea, and vomiting associated with food intolerance and weight loss severe enough to require a leave of absence from school. She had undergone two attempts of angioplasty of the celiac artery followed by laparoscopic release of the MAL and celiac plexus removal at an outside institution. Upper and lower endoscopy was repeated and she underwent cholecystectomy for biliary dyskinesia without clinical improvement. An angiogram with dynamic inspiration and expiration phases was performed, which was concerning for recurrent compression of the celiac artery. Given failure of all other treatment modalities, she was taken to the operating room for an infrarenal aorta to common hepatic artery bypass with PTFE. The patient has progressed well, and at her 3-month post-operative visit she was symptom-free and had gained 13 lbs. A 55-year old male presented to the office with complaint of postprandial abdominal pain, nausea, and vomiting with weight loss of 25 lbs in 9 months. Thorough gastrointestinal workup had been performed, including upper and lower endoscopy, 24-hour pH study, esophageal manometry, and exclusion of malignancies. Diagnostic visceral ultrasound demonstrated significantly elevated velocities in the celiac artery. Dynamic angiography demonstrated compression of the celiac artery with inspiration. The patient underwent laparoscopic median arcuate ligament release. At his 3-month post-operative visit, his symptoms were resolved and he had gained 9 lbs. Post-operative mesenteric duplex demonstrated patent celiac artery with velocities decreased from the preoperative study. CONCLUSIONS:
Diagnosis of MALS requires thorough gastrointestinal workup. While intervention typically starts with minimally invasive options, failure to control symptoms may lead to more definitive vascular reconstruction. These two cases of MALS in young patients at a community hospital demonstrate that treatment is patient-dependent but favor a minimally invasive option before pursuing aggressive means.
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