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Multi-visceral Arterial Compression By The Median Arcuate Ligament In A 33-year-old Female
Taleen A. MacArthur, MD, Manju Kalra, MBBS, Melinda S. Schaller, MD.
Mayo Clinic, Rochester, MN, USA.
Demographics: This patient is a 33-year-old female. History: This patient has a history significant for renovascular hypertension due to fibromuscular dysplasia, robotic assisted partial right nephrectomy, Hashimoto thyroiditis, fibromyalgia, and anxiety. She presented to clinic with post-prandial abdominal pain, bloating, and nausea that had worsened over the last six months, leading to food fear. She underwent a dynamic CT angiogram of the abdomen and pelvis. This demonstrated fixed, high-grade narrowing of the celiac artery secondary to compression by the median arcuate ligament (MAL), as well as high grade stenosis of the superior mesenteric artery (SMA) on expiration, also with compression from the MAL (Figure 1A). She underwent a celiac plexus block resulting in significant relief of her symptoms for several hours, allowing her to eat without difficulty. Plan: The patient was brought to the operating room for an open MAL release, neurolysis, and celiac ganglionectomy. A midline laparotomy incision was made and the supraceliac aorta was exposed anteriorly. Tight compression of the entire celiac trunk by a bulky MAL was apparent (Figure 1B). Each branch of the celiac trunk including the common hepatic, splenic, and left gastric arteries were sequentially skeletonized and controlled with vessel loops, clearing off all overlying tissue. The MAL was divided and resected. The celiac trunk was circumferentially dissected free, allowing for complete neurolysis (Figure 1C). Bulky celiac ganglia were identified and resected. She was dismissed home on post-operative- day five. Three months post-operatively she is tolerating a general diet with substantial improvement in her symptoms. CT angiogram demonstrates patent celiac and SMA without any extrinsic compression (Figure 1 D). Discussion: MAL syndrome is most commonly due to compression of the celiac artery, but in rare cases, compression of the SMA can also contribute to symptoms of chronic mesenteric ischemia. In these cases, if the SMA is otherwise healthy, a standard open MALS release with complete neurolysis will alleviate extrinsic compression of both the celiac and SMA, without need for further intervention for the SMA specifically.
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