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Median arcuate ligament syndrome or celiac artery compression syndrome is one of the abdominal vascular compression syndromes due to compression of proximal celiac artery by the median arcuate ligament. The median arcuate ligament unites diaphragmatic crura on either side at the level of aortic hiatus. The ligament has a low insertion causing compression of the celiac artery resulting in clinical symptoms of postprandial pain and weight loss. It is a rare syndrome, detected incidentally on routine Computed Tomography abdomen and pelvis studies. We present a rare case of a 35-year-old female who presented with abdominal pain. She was evaluated by Computed Tomography scan of the abdomen and pelvis. Ultrasound Doppler of mesenteric vasculature helped detect celiac artery stenosis. A referral to the vascular surgery department was made; however, the patient was managed conservatively.

Background Pancreaticoduodenal artery aneurysms (PDAAs) are rare visceral aneurysms, and prompt intervention/treatment of all PDAAs is recommended at the time of diagnosis to avoid rupture of aneurysms. Herein, we report two cases of PDAA caused by the median arcuate ligament syndrome, treated with surgical revascularization by aortosplenic bypass followed by coil embolization. Case presentation Case 1 A 54-year-old woman presented with a chief complaint of severe epigastralgia and was diagnosed with two large fusiform inferior PDAAs and celiac axis occlusion. To preserve the blood flow of the pancreatic head, duodenum, liver, and spleen, we performed elective surgery to release the MAL along with aortosplenic bypass. At 6 days postoperatively, transcatheter arterial embolization was performed. At the 8-year 6-month follow-up observation, no recurrent perfusion of the embolized PDAAs or rupture had occurred, including the non-embolized small PDAA, and the bypass graft had excellent patency. Case 2 A 39-year-old man who had been in good health was found to have a PDAA with celiac stenosis during a medical checkup. Computed tomography and superior mesenteric arteriography showed severe celiac axis stenosis and a markedly dilated pancreatic arcade with a large saccular PDAA. To preserve the blood flow of the pancreatic arcade, we performed elective surgery to release the MAL along with aortosplenic bypass. At 9 days postoperatively, transcatheter arterial embolization was performed. At the 6-year 7-month follow-up observation, no recurrent perfusion or rupture of the PDAA had occurred, and the bypass graft had excellent patency. Conclusion Combined treatment with bypass surgery and coil embolization can be an effective option for the treatment of PDAAs associated with celiac axis occlusion or severe stenosis.

A 61-year-old man presented with retroperitoneal hemorrhage caused by an aneurysm rupture of the pancreaticoduodenal arcade (PDA), and acute celiac artery dissection distal to celiac axis stenosis. Owing to the gradual growth of the false lumen, we planned to deploy a stent to the celiac artery dissection and embolize the PDA aneurysm. Prior to stent placement, we assessed the acute celiac artery dissection distal to the stenosis using four-dimensional computed tomography (CT) angiography through expiration/inspiration/expiration cycle. We diagnosed median arcuate ligament syndrome considering that the celiac axis showed a hooked narrowing at end-expiration, and the compression decreased at end-inspiration. Additionally, the true lumen distal to the stretched axis dilated in the inspiration phase. Therefore, we could advance a catheter into the true lumen during inspiration and successfully deploy a stent. Subsequently, laparoscopic median arcuate ligament release was performed after the stent deployment. A postoperative CT scan showed good patency in the stent, with disappearance of the blood filling the false lumen and with reduced celiac axis stenosis.

Celiac artery compression is a rare condition in which the celiac artery is compressed by the median arcuate ligament. Case reports of compression after trauma are hard to find. Blunt traumatic pericardium rupture is also a rare condition. We report a single patient who experienced both rare conditions from a single blunt injury. An 18-year-old woman was brought to the trauma center after a fatal motorcycle accident, in which she was a passenger. The driver was found dead. Her vital signs were stable, but she complained of mild abdominal pain, chest wall pain, and severe back pain. There were no definite neurologic deficits. Her initial computed tomography (CT) scan revealed multiple rib fractures, moderate lung contusions with hemothorax, moderate liver injury, and severe lumbar spine fracture and dislocation. She was brought to the angiography room to check for active bleeding in the liver, which was not apparent. However, the guide wire was not able to pass through the celiac trunk. A review of the initial CT revealed kinking of the celiac trunk, which was assumed to be due to altered anatomy of the median arcuate ligament caused by spine fractures. Immediate fixation of the vertebrae was performed. During recovery, her hemothorax remained loculated. Suspecting empyema, thoracotomy was performed at 3 weeks after admission, revealing organized hematoma without pus formation, as well as rupture of the pericardium, which was immediately sutured, and decortication was carried out. Five weeks after admission, she had recovered without complications and was discharged home.

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

A large group of patients with significant asymptomatic or low-symptomatic coeliac trunk stenosis require deeper consideration. On angiography, CT and MRI, 10–24% of examined patients are found to have their coeliac trunk compressed by the median arcuate ligament of the diaphragm. The associated median arcuate ligament syndrome, which is also called coeliac trunk compression syndrome or Dunbar syndrome, is rarely fully symptomatic. It is estimated that there are up to 7% of patients with such a clinical presentation. An asymptomatic or low-symptomatic course of the disease in patients with the syndrome is mainly explained by a developed collateral circulation, particularly involving the arterial arcades of the head of pancreas. In such cases, CT angiography detects collateral circulation in 22–69.6% of examined patients. The present authors often observed coeliac trunk blood flow to normalise in a standing position. According to them, the main causative factor for this phenomenon is the deflection of the coeliac trunk and its compression against the aorta by a lowered left lobe of the liver. The researchers observed it in many individuals; in this study, 5 cases are presented.

To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.

Background Dunbar syndrome or median arcuate ligament syndrome is a rare disorder. In this disorder, a malposition of the arcuate ligament compresses the celiac trunk and causes nonspecific symptoms including postprandial pain, abdominal bruit and weight loss. Surgical management is the primary treatment. Pancreatic neuroendocrine tumors (PNETS) are also rare. It comprises about 1–3% of pancreatic neoplasm. The patient could be symptomatic or asymptomatic depends on the tumor being functional or nonfunctional. In addition, surgical therapy is the choice. Case presentation In this paper, we report a case of 28 old female patient complaining from a long term of recurrent abdominal pain that doesn't releive on any kind of treatment, the multislices computerised tomography scan showed compress of the median arcuate ligament with an incidental mass in the tail of pancreas turned out to be a pancreatic neuroendocrine tumor. Conclusions The Dunbar syndrome and the Pancreatic neuroendocrine tumors must be kept in mind of phyciciens while the differential diagnosis of any recurrent abdominal pain., Highlights • Dunbar syndrome or median arcuate ligament syndrome is a rare disorder which presented with abdominal pain. • Celiac artery compression can be diagnosed with Multi slices computer tomography and selective catheter angiography, surgery is the treatment of choice. • The Dunbar syndrome and the Pancreatic neuroendocrine tumors must be kept in mind during differential diagnosis of recurrent abdominal pain.

Highlights • Celiac artery compression is a rare and under diagnosed condition in females with chronic abdominal pain. • Diagnosis is mainly through symptoms corelated with the angiogram findings. • Surgical division of the median arcuate ligament, celaic plexus and celiac ganglia is the main stay of the treatment. • Laparoscopic or robotic assisted technique is safe and preferred modality., Introduction Celiac artery compression syndrome is a rare disorder found mainly in young females. It many a times goes undiagnosed as the symptoms are non-specific and varied. Presentation of the case We present a case of celiac artery compression syndrome in a young female where laparoscopic median arcuate ligament release with celiac ganglionectomy was effective in relieving the symptoms. Discussion Commonly they may present with abdominal pain, vomiting and diarrhea but there is absence of significant clinical signs. High level of suspicion and the right imaging techniques like the lateral aortogram, helps us to clinch the diagnosis. Conclusion Laparoscopic release of celiac artery compression is a safe and effective method to treat this uncommon disease.

Median arcuate ligament syndrome is the result of celiac axis compression by the diaphragmatic crura. Although the celiac artery is the most common vessel to have compression, the renal arteries may also rarely be compressed by the crural fibers of the diaphragm, which may cause secondary hypertension. We present two cases of renovascular hypertension secondary to renal artery compression by the diaphragmatic crura. The first patient was treated with open decompression and wide resection of the crural fibers, and the second patient was decompressed laparoscopically. Neither case required renal artery reconstruction. Antihypertensives were discontinued in both patients postoperatively.

Diagnostic imaging after orthotopic liver transplant focuses primarily on depicting complications related to surgical hepatic vascular and biliary anastomoses. Less common preexisting vascular conditions include congenital anatomic variants, atherosclerosis, chronic portal venous thrombosis, splenic artery and variceal steal phenomena, and transarterial embolization (TAE) for hepatocellular carcinoma (HCC). If unappreciated or left untreated preoperatively, these conditions negatively impact the transplant by impairing hepatic arterial or portal vascular inflow. Many of the complications related to preexisting vascular conditions can be prevented or mitigated by proper performance and careful evaluation of preoperative imaging studies. The authors describe the diagnosis and treatment of complications arising from narrowing of the celiac axis by atherosclerosis and the median arcuate ligament, variant anatomy of the hepatic artery, insufficiency of the portal vein requiring surgical conduits, and large varices or an enlarged splenic artery and spleen that may steal blood and compromise hepatic arterial or venous inflow. While preoperative evaluation primarily involves CT and MRI, postoperative diagnosis involves screening with sonography and confirmation with other modalities. We propose the use of a preoperative checklist of vascular status and measurements in patients undergoing liver transplant. Reports of imaging studies in recipients after transplant should include details of surgical vascular anastomoses and conduits, any history of HCC and preoperative TAE, details of the preoperative α-fetoprotein levels, and any unusual procedures or pathologic findings in the explanted liver that may affect postoperative surveillance. The authors review the pretransplant imaging evaluation of vascular and HCC issues that may affect surgical outcomes and methods to help recognize complications after transplant that can arise from these conditions.©RSNA, 2020.

Highlights • Median Arcuate Ligament syndrome (MALS) is also known as Durban syndrome. • MALS is a rare condition. • MALS must be considered in case of refractory post-surgical abdominal pain. • Angiotomography is accessible and reliable for making the diagnosis., Introduction Dunbar syndrome is a rare anatomical abnormality characterized by the extrinsic compression of the celiac trunk by the median arcuate ligament (MAL). Though it is rarely misdiagnosed, the clinical diagnosis may be difficult, especially after complex visceral surgery such as esophagectomy. Presentation of case A 62-year-old male patient with a squamous cell carcinoma of the distal esophagus, placed under trimodal treatment (chemotherapy, radiotherapy followed by hybrid minimal invasive 2-field esophagectomy) presented with abdominal pain refractory to analgesics, anti-spasmodic, opioids, and neuronal celiac plexus ablation in the late post-operative period. He was diagnosed with extrinsic celiac trunk compression based on abdominal angiotomography findings. Retrospectively, similar images were found in conventional abdominal tomography at pre-operative staging, but this time, the patient had only dysphagia. After surgical treatment of MAL, the patient had total relief of pain and symptoms. Discussion Abdominal pain after complex surgical procedures is very frequent and its investigation is mandatory, even more after refractory clinical management. Dunbar syndrome is related to ambiguous abdominal pain. It is uncommon and its diagnosis with angiotomography is accessible. Conclusion Vascular disorders should be investigated in cases of abdominal pain after complex surgical procedures.

Median arcuate ligament syndrome is a rare and poorly understood condition that can have a significant impact on the quality of life of patients. Diagnosis is often difficult and delayed because of the need to exclude other pathologic processes. Treatment strategies traditionally involve open or laparoscopic division of the median arcuate ligament, with or without vascular reconstruction. This report portrays a case of median arcuate ligament syndrome with compression of two visceral arteries and distal embolic complications. A novel hybrid technique is described using intravascular ultrasound technology to aid in laparoscopic median arcuate ligament division. This allowed real-time intravascular visualization of the compressive segment, guided release of the ligament fibers, and demonstrated confirmation of decompression. Keywords: Vascular surgery, Intravascular ultrasound, Median arcuate ligament syndrome

Introduction: Median arcuate ligament or Dunbar syndrome is a rare vascular disorder causing celiac trunk stenosis or occlusion due to the extrinsic compression by the median arcuate ligament. A visceral aneurysm may develop as a complication.Patients and methods: We experienced an inferior pancreaticoduodenal artery aneurysm presentation in two female patients with the median arcuate syndrome previously diagnosed. One patient presented with postprandial abdominal pain and weight loss and the other one was asymptomatic.Results: We described our experience with the both patients being successfully treated surgically.Conclusions: Awareness of possible repercussions of the celiac trunk stenosis to peripancreatic arteries should be elevated. Restoration of physiological blood flow by removing pathologic anatomy should be performed. Since there is no correlation between the size of a visceral aneurysm and the risk of rupture, having a high postrupture mortality, pancreaticoduodenal artery aneurysms should be treated even if asymptomatic. Surgical treatment remains the mainstay treatment of the Dunbar syndrome complicated by visceral aneurysms.

Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.

Background Patients with chronic occlusion of the celiac artery and superior mesenteric artery (SMA) are often asymptomatic, and occlusion may be caused by arteriosclerosis or median arcuate ligament compression. Pancreaticoduodenectomy (PD) is occasionally performed for patients with celiac artery occlusion; however, reports on patients with SMA occlusion are rare. We report a patient with cholangiocarcinoma and total atherosclerotic occlusion of the SMA without preoperative stenting or bypass. Case presentation A 73-year-old man suspected to have lower bile duct carcinoma was admitted to our hospital for further treatment. Three-dimensional computed tomography (3DCT) showed a common bile duct tumor and total occlusion of the SMA with collateral circulation of the gastroduodenal artery (GDA) and inferior mesenteric artery (IMA). We performed a PD. During the operation, we used test clamping of the GDA, which revealed no bowel ischemia. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 30. 3DCT on POD 98 and POD 307 showed development of collateral circulation between the IMA and SMA. Conclusion Here, we report the case of a patient with total occlusion of the SMA who subsequently underwent PD. 3DCT was instrumental in gathering vascular collateral information and thus we conclude that the assessment of collateral circulation before surgery is important.

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is one of the many rare vascular compression syndromes attributed to celiac trunk compression by the median arcuate ligament of the diaphragm, with presentations ranging from completely asymptomatic to myriad gastrointestinal symptoms, including chronic abdominal pain (CAP), post-prandial pain, nausea and vomiting, anorexia, early satiety, and subsequently weight loss. We present a case of a 50-year-old female presenting with ongoing multiple chronic gastrointestinal symptoms, later attributed to the marked narrowing of her celiac axis secondary by the median arcuate ligament.

BACKGROUND Multiple retrospective studies have demonstrated the safety and feasibility of laparoscopic median arcuate ligament division with celiac neurolysis for the definitive management of median arcuate ligament syndrome (MALS). This study queries the clinical equipoise of robotic (RMALR) versus laparoscopic MAL release (LMALR) at a high-volume center. METHODS A retrospective analysis of consecutive 26 RMALR and 24 LMALR between March 2018 and August 2019 by a single surgeon at a quaternary academic institution was completed. Primary endpoint was postoperative decrease in celiac trunk expiratory peak systolic velocities (PSVs) measured by mesenteric duplex ultrasonography. Secondary outcomes included reported improvement in MALS-related clinical symptoms, distribution of first assistant seniority level, and involvement of second assistants in RMALR versus LMALR. RESULTS Mean operative times for LMALR and RMALR were 86 and 134 min, respectively (p

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.

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, celiac axis syndrome, and Dunbar Syndrome, is a rare disorder that results from compression of the celiac artery by the median arcuate ligament. The following is a case that depicts an interesting presentation of a patient diagnosed with this rare condition. A 44-year-old male with a history of mutism was brought in by his family for weight loss of 100 lbs with intermittent abdominal pain, weakness and lethargy over a period of five years. His family reported that he had poor nutritional intake, and could only eat a small amount before he seemed to be in pain, and eventually refused to eat. He had no other prior medical history except for mutism, no family history of malignancy, no history of trauma, surgeries, smoking or substance use, and did not take any medications. Physical exam was largely unremarkable. Mesenteric vascular duplex demonstrated severe grade stenosis of the celiac trunk with post-stenotic velocity of 520 cm/sec. Contrast enhanced computed tomography angiography revealed acute angle J-configuration of the takeoff of the celiac axis, with stenosis at its origin and focal post-stenotic dilatation, confirming the diagnosis of CACS. CACS is an elusive diagnosis that should be considered in patients where other causes of abdominal pain and weight loss have been ruled out. The disease can present with the classic triad of post-prandial abdominal pain, weight loss, and an abdominal bruit. Imaging modalities including mesenteric vascular duplex, computed tomography abdominal angiography, magnetic resonance angiography and celiac artery angiography can help make the diagnosis. Treatment involves surgical decompression via division of the median arcuate ligament, with most patients experiencing significant and long-lasting relief from their symptoms.

Transcatheter arterial embolization (TAE) is the standard of care for haemodynamically-stable patients with blunt hepatic injury but it is sometimes impossible due to unfavourable vascular anatomies. This case report describes a 43-year-old male patient with abdominal pain following a motorcycle accident. Based on computed tomography (CT) findings, he was diagnosed with high-grade hepatic injury with coeliac axis stenosis (CAS) due to compression by the median arcuate ligament, and an aberrant right hepatic artery. Contrast-enhanced ultrasonography (CEUS) demonstrated multiple high echogenic tubular and ovoid structures suggestive of active bleeding within the injured liver area. Angiography revealed unique interlobar and intrahepatic collateral vessels between the right and left hepatic arteries. Liver haemorrhages were also identified. Catheterization of the feeding arteries through the collateral pathway was unsuccessful, so a decision was made to cannulate the stenotic portion of the coeliac trunk with a 5-Fr Yashiro catheter. After several attempts, the microcatheter was successfully advanced coaxially into the common hepatic artery. Embolization was performed with a 1:2 mixture of N-butyl cyanoacrylate and iodized oil. Successful haemostasis was confirmed following TAE. CEUS helped clinicians identify active bleeding following traumatic solid organ injury. TAE was a safe and effective treatment strategy. Before performing TAE, attention should be given to the presence of CAS associated with compression by the median arcuate ligament.

Background Median arcuate ligament syndrome (MALS), which results from compression of the median arcuate ligament (MAL), is a rare cause of abdominal pain and weight loss. Treatment is dissection of the MAL; however, the laparoscopic procedure is not yet established and it involves the risk of major vascular injury, especially in cases with an anomaly. Case presentation A 47-year-old man was evaluated at the hospital for epigastric pain. Contrast computed tomography scan revealed stenosis of the celiac artery origin due to the MAL. An Adachi V type vascular anomaly was also observed. Laparoscopic treatment was performed to release pressure on the celiac artery. Laparoscopic ultrasonography was used to less invasively confirm the release of the MAL. Despite a concomitant Adachi V type vascular anomaly, surgery was safely performed using the laparoscopic magnification view and intraoperative ultrasonography. Follow-up ultrasonography confirmed the celiac artery stenosis has not recurred. Conclusions A rare case of MALS with an Adachi V type vascular anomaly is presented and the laparoscopic treatment is detailed.

Introduction: Ischemic complications are a notable cause of morbidity in patients after pancreatic head resections. Stenosis of celiac axis in patients undergoing pancreatoduodenectomy requires further perioperative attention. Case report: We present a patient with pancreatic head malignancy scheduled for Whipple procedure in the setting of hemodynamically significant celiac axis stenosis. Despite release of the artery from compression by median arcuate ligament, elevation of liver function tests on the first postoperative day was noted. Endovascular stenting was performed on the same day with significant radiological improvement and subsequent normalization of laboratory values. The patient had no further postoperative complications. Conclusion: Fast recognition of ischemic complications after pancreatic head resection is crucial. Even postoperatively, endovascular intervention might be a feasible treatment modality of celiac axis stenosis in selected patients who undergo pancreatoduodenectomy.

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare condition in which the celiac artery is compressed by the median arcuate ligament of the diaphragm. We hereby report a case of a 48-year-old female presenting with long-standing abdominal pain and ninety-pound weight loss who was found to have median arcuate ligament syndrome after extensive workup.

Median arcuate ligament syndrome (MALS) is the chronic symptomatic compression of the celiac artery by the median arcuate ligament. A known potential sequela of MALS is celiac artery aneurysm, which could predispose the diseased artery to dissection. However, the presence of celiac artery dissection and MALS is yet to be reported. Here, we present a case of MALS with a coincident celiac artery aneurysm and dissection.

Objective The crural diaphragm is responsible for pulmonary ventilation in the early period after lobectomy. However, the role of its thickness in pulmonary ventilation remains unclear. We investigated the impact of crural diaphragm thickness on pulmonary oxygenation and gas exchange early after lobectomy. Methods We enrolled 32 patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic lobectomy. Crural diaphragm thickness was defined as the average of the maximum thicknesses of the right and left crural diaphragm at the level of the median arcuate ligament on computed tomography. Pulmonary oxygenation and gas exchange were evaluated by the ratio of arterial oxygen tension/fraction of inspiratory oxygen and alveolar-arterial oxygen difference on the second postoperative day. Results Crural diaphragm thickness of 7.0 ± 1.7 mm was associated with vital capacity. After lobectomy, arterial oxygen tension/fraction of inspiratory oxygen decreased significantly and alveolar-arterial oxygen difference increased significantly. Five patients with oxygen saturation via pulse oximetry ≤92% had a lower arterial oxygen tension/fraction of inspiratory oxygen and higher alveolar-arterial oxygen difference than the others. Crural diaphragm thickness in these patients was less than in the others (5.5 ± 1.9 vs. 7.3 ± 1.5 mm, p = 0.033). In multivariate analysis, crural diaphragm thickness remained an independent factor affecting arterial oxygen tension/fraction of inspiratory oxygen and alveolar-arterial oxygen difference ( p = 0.044, p = 0.049). Crural diaphragm thickness was positively associated with arterial oxygen tension/fraction of inspiratory oxygen and negatively associated with alveolar-arterial oxygen difference. Conclusion Crural diaphragm thickness affects pulmonary ventilation early after lobectomy.

Visceral aneurysms of the pancreaticoduodenal arcades are rare. Although these aneurysms are often asymptomatic and identified incidentally on cross-sectional imaging, aneurysm rupture presents significant morbidity. Ruptured pancreaticoduodenal arcade aneurysms typically present with abdominal pain, hemorrhagic shock, or gastrointestinal bleeding. A 72-year-old male presented with nausea and vomiting and was found to have imaging evidence of duodenal obstruction. This was due to a duodenal intramural hematoma caused by a ruptured submucosal aneurysm supplied by a branch of the inferior pancreaticoduodenal artery in the presence of median arcuate ligament compression of the celiac artery. This was subsequently treated with endovascular embolization with clinical improvement in duodenal obstruction. This case illustrates an unusual presentation of a ruptured pancreaticoduodenal arcade aneurysm. Keywords: Pancreaticoduodenal artery aneurysm, Duodenal stenosis, Duodenal obstruction

espanolEl Sindrome del ligamento arqueado medio (SLAM) o Sindrome de compresion del eje celiaco (SCEC) es una condicion poco comun causada por la compresion externa del tronco celiaco por el ligamento arqueado medio. La sintomatologia comprende dolor abdominal, nauseas, vomito y perdida de peso. Tradicionalmente, la compresion del tronco celiaco es usualmente vista en la posicion sagital de tomografia computarizada donde aparece prominente en la espiracion, sin embargo, en casos severos, puede mostrarse como una compresion persistente en la inspiracion. Tipicamente, el tratamiento de este sindrome es una cirugia como una apertura clasica o una nueva division laparoscopica del ligamento arqueado medio para aliviar la compresion extrinseca. El tratamiento endovascular percutaneo es una tecnica alternativa y puede considerarse en casos seleccionados, para los cuales la cirugia tradicional fallo o fue una opcion de tratamiento. EnglishMedian arcuate ligament syndrome (MALS) or celiac axis compression syndrome (CACS) is an uncommon condition caused by the external compression of the celiac trunk by the median arcuate ligament. This symptom involves abdominal pain, nausea, vomiting, and weight loss. Traditionally, the compression of the celiac trunk is usually seen on the sagittal view of a computerized tomography scan where it appears prominent on expiration; however, in severe cases, it may be shown as a persistent compression on inspiration. Typically, the treatment of this syndrome is surgery such as a classic opening or a novel laparoscopic division of the median arcuate ligament to relieve the extrinsic compression Percutaneous endovascular treatment is an alternative technique and may be considered in selected cases, for which the traditional surgery failed or was a treatment option.

Median arcuate ligament syndrome (MALS) is a condition characterized by pain in the abdominal region attributed to compression of the celiac artery by the median arcuate ligament of the diaphragm during expiration. MALS is also known as celiac artery compression syndrome, celiac axis syndrome, or Dunbar syndrome. Pain may result from the tight pressing on the celiac nerves in the area. The patient usually presents with symptoms such as postprandial epigastric pain, weight loss, and, occasionally, an abdominal bruit. Furthermore, some individuals may experience nausea and vomiting. It may be an etiology of a rare disorder, chronic mesenteric ischemia.

Objective: Pancreaticoduodenal artery aneurysm is a rare vascular disorder that manifests with a clinical presentation ranging from asymptomatic cases to hemorrhagic shock due to aneurysm rupture. In this study, we aimed to evaluate the outcomes of patients treated with different methods for pancreaticoduodenal artery aneurysm. Material and Methods: A total of 5 patients who were treated and followed for pancreaticoduodenal artery aneurysm between January 2011 and January 2018 were enrolled in the study. Standard endovascular embolization and surgical resection were performed. The demographic findings and treatment outcomes were compared. Results: All patients were shown to have a pancreaticoduodenal artery aneurysm by radiological methods. The most common complaint was abdominal pain. The mean aneurysm size was 2.8 cm. Two patients had coeliac axis stenosis and occlusion, one had hypertension, one had Marfan syndrome, and one had chronic pancreatitis as the possible etiological cause. One patient with occlusion of the coeliac axis had thrombus, one patient with coeliac axis stenosis had median arcuate ligament compression. Three patients were treated with embolization, one with surgery, and one with low-molecular weight heparin. Conclusion: Different etiological factors and multiple vascular problems accompanying the disorder create difficulties for establishing a treatment algorithm. Due to the rare nature of the disease, studies available in the literature involve limited numbers of patients, as was also the case in our study. There appeared to be no significant differences between the treatment and follow-up duration among the different treatment methods we applied for our patients.

Background: Median arcuate ligament syndrome (MALS) is a condition characterised by chronic abdominal symptoms associated with median arcuate ligament (MAL) compression of the coeliac artery. Aim: In this observational study, we aimed to evaluate the outcomes of laparoscopic treatment in patients with MALS. Materials and Methods: The data of ten patients with MALS who were subjected to laparoscopic sectioning of the MAL were retrospectively reviewed. The following data were evaluated: age, gender, clinical and diagnostic test findings, American Society of Anaesthesiologists score, operative findings and complications and mortality, hospital stay duration and hospital readmission. The diagnosis of MALS was established by computed tomography (CT) angiography. Results: Six (60%) of ten patients with MALS were female and four (40%) were male. The mean age was 42.4 +/- 12.3. The main symptoms were epigastric pain (100%) and weight loss (60%). CT angiography showed high-grade stenosis of the anterior wall of the proximal coeliac trunk and post-stenotic dilation caused by extrinsic compression of the MAL. Surgical procedure was uneventful in all patients. Operating time was 155.5 min (120-200) and intra-operative blood loss was 150 ml (100-250). Length of stay was 3.1 day (2-9), with no mortality. The post-operative complications developed in two female patients. One of them developed ileus and the other patient developed pulmonary thromboembolism. At 6-month follow-up, all patients were asymptomatic. Conclusion: Laparoscopic decompression is an effective treatment for MALS and can provide symptomatic relief. This method may be the preferred modality of treatment in view of its lack of morbidity and good results.

Median arcuate ligament (MAL) syndrome is a clinical syndrome caused by the compression of the celiac artery (CA) by the MAL. This study aimed to present the detailed anatomy and a step-by-step procedure of CA decompression for MAL syndrome. The CA decompression procedure involves exposing the diaphragmatic crura and aorta, taping the left gastric artery, and dividing the compressive tissues. The MAL and ganglionic tissue, which form a broad band with multiple layers overlying the CA, comprise the compressive tissues. Therefore, the compressive tissues overlying the CA are encircled and divided one by one until the CA stenosis is released. CA decompression is confirmed with intraoperative duplex ultrasonography of the CA, with a return to normal peak systolic velocities without variation between deep inspiration and expiration. This report presents the detailed anatomy and procedural steps for CA decompression in MAL syndrome.

Highlights • The treatment of median arcuate ligament syndrome is the surgical release of the ligament. • Symptomatic patients need the ligament release with wide excision of the celiac plexus. • However, the majority of the patients with celiac artery compression remains asymptomatic. • It might be enough to just release the ligament without ganglionectomy for asymptomatic patients. • Hybrid operating room could allow for adequate ligament release without ganglionectomy., Introduction Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) causes compression of the celiac artery (CA) and plexus. Although 13–50 % of healthy population exhibit radiologic evidence of the CA compression, the majority remains asymptomatic. With or without symptoms, MALS have a risk of developing collateral circulation that leads to pancreaticoduodenal artery (PDA) aneurysms that have high risk of rupture. The treatment of MALS is the surgical release of the MAL. However, the necessity of ganglionectomy of the celiac plexus is still unclear. Presentation of case A 60-year-old man with a ruptured PDA aneurysm caused by MALS was admitted to our hospital for an emergency. After treatment for the ruptured PDA aneurysm by transcatheter arterial coil embolization, he underwent elective laparoscopic MAL release in the hybrid operation room to check blood flow of the CA intraoperatively. The angiography of the CA immediately after MAL release without ganglionectomy of the celiac plexus showed the antegrade blood flow to the proper hepatic artery instead of the retrograde flow via the pancreaticoduodenal arcade. The postoperative course was uneventful and the follow-up computed tomography revealed no residual CA stenosis. Discussion Unlike symptomatic MALS, it might be enough to just release the MAL without ganglionectomy of the celiac plexus for asymptomatic MALS, especially that with the treated PDA aneurysm. Conclusion Laparoscopic treatment of MALS in hybrid operating room could allow for adequate MAL release without ganglionectomy of the celiac plexus using the intraoperative angiography of the CA.

Median arcuate ligament syndrome (MALS), otherwise called celiac artery compression syndrome (CACS), is an uncommon disorder that results from an anatomical compression of the celiac axis and/or celiac ganglion by the MAL. Patients typically present with abdominal pain of unknown etiology exacerbated by eating along with nausea, vomiting, and weight loss. MALS is a diagnosis of exclusion that should be considered in patients with severe upper abdominal pain, which does not correlate with the objective findings. The cardinal feature which is elicited in the diagnosis of MALS relies on imaging studies of the celiac artery, demonstrating narrowing during expiration. The definitive treatment is the median arcuate ligament’s surgical release to achieve surgical decompression of the celiac plexus by division of the MAL. This article describes our experience with this entity, focusing on symptom presentation, diagnostic challenges, and management, including long-term follow-up in four cases.

Background Median arcuate ligament (MAL) syndrome (MALS), also known as celiac artery (CA) compression syndrome and Dunbar syndrome, occurs because of extraluminal compression of the CA root by the MAL, which is part of the diaphragm. In MALS, a malposition of the MAL compresses the CA and causes nonspecific symptoms, including epigastric pain after eating, weight loss, nausea, and vomiting and can sometimes cause visceral aneurysms. Typically, in MALS, various chronic ischemic symptoms and visceral aneurysms due to changes in arterial blood flow are observed; however, in acute-onset MALS, acute organ failure due to ischemic changes may be problematic. Surgical treatment is the recommended treatment for MALS, but the optimal treatment of acute MALS that occurs after laparotomy remains controversial because of its rarity. Here, we present the first case of acute MALS, which occurred after pancreaticoduodenectomy (PD) that was successfully treated with interventional radiology (IVR) without reoperation. Case presentation A 75-year-old man presented with liver infarction after subtotal stomach-preserving PD using the Child method plus Braun enteroenterostomy. As a result of contrast-enhanced computed tomography for the investigation of elevated hepatic cytolysis-related enzymes on the first postoperative day, he was diagnosed with acute MALS resulting from gastrointestinal reconstruction after PD. The patient underwent IVR to restore blood flow of the CA, and an intraluminal stent was inserted. Despite the development of ischemic gastropathy, splenic infarction, and pancreatic fistula, the patient was eventually discharged on postoperative day 82 without any disability. Conclusion Many studies have reported open, laparoscopic, and robot-assisted MAL incisions for MALS, but few reports have detailed the treatment for postoperative MALS. Here, we report the first case of acute MALS developed after PD that was successfully treated with endovascular CA stenting. For acute MALS after PD, early endovascular treatment may be more useful than re-laparotomy.

Coeliac artery compression stenosis caused by the median arcuate ligament can lead to aneurysm formation in the pancreatico-duodenal arteries that can eventually result in a spontaneous rupture leading to retroperitoneal haemorrhage. In this case series, we describe the cases of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma, complicating a median arcuate ligament syndrome.

True aneurysms of the peri-pancreatic arcade (PDAA) have been attributed to increased collateral flow related to coeliac axis (CA) occlusion by a median arcuate ligament (MAL). Although PDAA exclusion is currently recommended, simultaneous CA release and the technique to be used are debated. The aim of this retrospective multicentre study was to compare the results of open surgical repair of true non-ruptured PDAA with release or CA bypass (group A) vs. coil embolisation of PDAA and CA stenting or laparoscopic release (group B).From January 1994 to February 2019, 57 consecutive patients (group A: 31 patients; group B: 26 patients), including 35 (61%) men (mean age 56 ± 11 years), were treated at three centres. Twenty-six patients (46%) presented with non-specific abdominal pain: 15 (48%) in group A and 11 (42%) in group B (p = .80).No patient died during the post-operative period. At 30 days, all PDAAs following open repair and embolisation had been treated successfully. In group A, all CAs treated by MAL release or bypass were patent. In group B, 2/12 CA stentings failed at48 hours, and all MAL released by laparoscopy were successful. Median length of hospital stay was significantly greater in group A than in group B (5 vs. 3 days; p = .001). In group A, all PDAAs remained excluded. In group B, three PDAA recanalisations following embolisation were treated successfully (two redo embolisations and one open surgical resection). At six years, Kaplan-Meier estimates of freedom for PDAA recanalisation were 100% in group A, and 88% ± 6% in group B (p = .082). No PDAA ruptured during follow up. In group A, all 37 CAs treated by MAL release were patent, and one aortohepatic bypass occluded. In group B, five CAs occluded: four after stenting and the other after laparoscopic MAL release with two redo stenting and three aortohepatic bypasses. Estimates of freedom from CA restenosis/occlusion were 95% ± 3% for MAL release or visceral bypass, and 60% ± 9% for CA stenting (p = .001). Two late restenoses following CA stenting were associated with PDAA recanalisation.Current data suggest that open and endovascular treatment of PDAA can be performed with excellent post-operative results in both groups. However, PDAA embolisation was associated with few midterm recanalisations and CA stenting with a significant number of early and midterm failures.

Median arcuate ligament syndrome (MALS), also called celiac artery (CA) compression syndrome or Dunbar syndrome, is a rare clinical condition that involves compression of the celiac artery by median arcuate ligament at its origin. It is more common in young females and presents with weight loss, postprandial colicky pain, and nausea. It is a diagnosis of exclusion. Workup includes computed tomography (CT) with contrast, dynamic magnetic resonance imaging (MRI), and duplex scan. Imaging usually reveals narrowing of the celiac artery due to compression and downward angulation, leading to “fishhook” appearance. Duplex scan shows increased pressure in the celiac axis. Incising the median arcuate leads to symptomatic relief. Robotic approach provides a unique opportunity for meticulous dissection and precise incision of the ligament with faster recovery.

Median arcuate ligament syndrome (MALS) has been described for over a century, yet the etiology and pathophysiology are not well understood. Interestingly, postural orthostatic tachycardia syndrome (POTS) has been observed to be associated with MALS, with approximately 5% of POTS patients having the diagnosis of MALS also. Based on the most current literature available, this chapter will discuss the etiology, epidemiology, clinical features, diagnostic findings, therapeutic options, and anesthetic considerations for patients with POTS and MALS. The laparoscopic approach is now widely accepted as the standard for surgical treatment. The anesthetic management of these patients must include several unique considerations in the preoperative, intraoperative, and postoperative phases.

Median arcuate ligament syndrome (MALS) is the compression of the celiac artery (CA) by the median arcuate ligament. MALS can cause pseudoaneurysm of the gastroduodenal artery, which can lead to fatal bleeding. A 40-year-old male with no prior medical history presented with symptoms of upper gastrointestinal hemorrhage (UGIH). Severe duodenal bleeding was confirmed although endoscopic hemostasis was impossible and final hemostasis was achieved following a subsequent open duodenotomy. A postoperative computed tomographic angiography (CTA) visualized a significant CA stenosis, post-stenotic dilatation and an aneurysm on a jejunal branch artery. The patient underwent coiling of the gastroduodenal artery, gastroepiploic artery and two pancreaticoduodenal arterial branches. The patient was diagnosed with MALS and 6 months later underwent open resection of the median arcuate ligament. MALS should be considered as a rare cause of upper gastrointestinal bleeding. The literature and proposed treatments are discussed.

A boy aged 19 years presented to emergency room with severe postprandial upper abdominal pain and recent significant weight loss, with history of decompressive craniotomy for post-traumatic frontal lobe haemorrhage. CT scan revealed an acute indentation of coeliac artery with high-grade stenosis and post-stenotic dilatation, diagnostic of median arcuate ligament syndrome (MALS). MALS, a diagnosis of exclusion, is identified using patient’s accurate symptomatic description. Exclusion of other causes of abdominal angina in a patient with frontal lobe syndrome was a challenging job, as they lack critical decision-making ability. Hence, the decision to proceed with the complex laparoscopic procedure was made by the patient’s parents and the surgeon, with the patient’s consent. Laparoscopic release of the median arcuate ligament resulted in relief of the patient symptoms much to the relief of his parents and the surgeon.

Median arcuate ligament syndrome (MALS) is a rare condition which is due to the compression of celiac trunk by low riding of fibrous attachments of median arcuate ligament and diaphragmatic crura. Technically, MALS is a diagnosis of exclusion, consisting of vague symptoms comprising of postprandial epigastric pain, nausea, vomiting and unexplained weight loss. Different imaging modalities like Doppler ultrasound, computed tomography, magnetic resonance imaging and mesenteric angiogram are helpful to demonstrate celiac axis compression. The goal of treatment is decompression of celiac trunk either by open, laparoscopic or robotic method along with adjuvant interventional procedures like percutaneous transluminal angioplasty (PTA) and stenting. Surgical is the mainstay of treatment. This approach is based on open, laparoscopic or robotic release of compressed ligament along with celiac ganglionectomy and celiac artery revascularization. The role of interventional radiology is limited to angioplasty and stenting to open the stenosis rather than addressing the underlying compression of celiac trunk which has resulted in the symptoms. However, both the diagnosis and therapeutic intervention remains challenging. Extensive evaluation of etiology and pathophysiology of MALS and addressing the same through minimally invasive techniques may yield best prognosis in future. In this review article, we discuss briefly about the MALS in terms of etiology, diagnosis and its management including the role of interventional radiology.

Patient: Male, 55-year-old Final Diagnosis: Dunbar syndrome Symptoms: Epigastric pain • weight loss Medication: — Clinical Procedure: None Specialty: Gastroenterology and Hepatology • Radiology Objective: Rare disease Background: Dunbar syndrome is a rare vascular alteration caused by the abnormal course of the median arcuate ligament of the diaphragm, which in some patients causes chronic compression of the celiac artery and can cause non-specific symptoms such as diarrhea, retro-sternal pain, vomiting, swelling, and nausea, or a typical symptomatic triad with weight loss, post-prandial abdominal pain, and epigastric murmur. Color Doppler ultrasound and duplex Doppler ultrasound provide a complete diagnostic framework of this disease. Case Report: We describe a case of 55-year-old man with post-prandial epigastric pain, significant weight loss, and several episodes of retro-sternal pain. He underwent multidetector computed tomography of the abdomen and color duplex Doppler ultrasound examination of the celiac artery that highlighted stenosis of the celiac artery, more severe in expiratory apnea. The computed tomography showed the typical aspect of the celiac artery, with the “hook sign”. A duplex Doppler ultrasound examination showed a significant increase in peak speed (226 cm/s) due to severe stenosis of the celiac artery by the median arched ligament of the diaphragm. Conclusions: This case is unique due to the severity of the celiac artery stenosis and the unusual clinical presentation of the patient who had frequent episodes of retro-sternal pain. The significant increase in peak velocity in the celiac artery in expiratory apnea, if associated with the typical symptomatology in the absence of other alterations of the splanchnic vessels, can be considered, in our opinion, sufficient for the diagnosis of Dunbar syndrome.

Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.

Dunbar syndrome also known as median arcuate ligament syndrome (MALS) or celiac artery compression syndrome (CACS) is a rare syndrome resulting from the external compression of the celiac trunk from the median arcuate ligament. A 78-year-old female with multiple chronic conditions presented with intermittent, post-prandial epigastric pain associated with early satiety, decreased appetite for òne year. Multiple tests including gastric emptying scan and hepatobiliary scan with cholecystokinin (CCK) were normal. Contrast-enhanced computed tomography (CECT) abdomen/pelvis showed thickening of a median arcuate ligament. Further imaging with end-inspiratory phase computed tomography (CT) angiography of the abdomen and 3D reconstruction of images, revealed approximately 1 cm length segment of proximal celiac arterial narrowing, measuring 70% maximally (at its origin) and characteristic hooked appearance of the proximal celiac artery with post-stenotic dilation diagnostic of MALS. Our case report emphasizes the importance of MALS in the differential diagnosis of chronic, intermittent abdominal pain.

Patient: Female, 45-year-old Final Diagnosis: Multiple splanchnic artery aneurysms secondary to median arcuate ligament syndrome • occlusion of the coeliac trunk • significant stenosis of the superior mesenteric artery Symptoms: Abdominal pain • postprandial abdominal pain • weight loss Medication:— Clinical Procedure: Aorto-hepatic bypass • endovascular aneurysm embolization Specialty: Surgery Objective: Rare disease Background: Median arcuate ligament syndrome (MALS) is a rare and often misdiagnosed condition affecting about 0.4% of the population, typically ages 20–50 years old, and more frequently females. Caused by the compression of the celiac artery and adjacent nervous structures by the median arcuate ligament, it is typically manifested by postprandial abdominal pain, nausea or vomiting, and loss of weight. This condition also results in compensatory increased blood flow in peripancreatic arcades, facilitating formation of true aneurysms of the visceral vessels. Case Report: A 45-year-old woman with hypertension and left inferior renal pole cysts was referred to our department due to chronic, recurrent postprandial abdominal pains, nausea, and weight loss of approximately 15 kg in 1 year. A computed tomography (CT) scan demonstrated complete occlusion of the celiac trunk, significant stenosis of the superior mesenteric artery, and multiple aneurysms up to 17 mm in collateral circulatory vessels. Surgical decompression of the median arcuate ligament was performed and venous bypass was implanted between the aorta and the common hepatic artery, resulting in restoration of proper blood in the visceral circulation. Subsequently, 2 endovascular embolizations of visceral aneurysms were successfully performed. In the 48-month follow-up period, there was resolution of symptoms and no aneurysm formation was observed. Conclusions: Endovascular methods should be the treatment of choice in patients with splanchnic artery aneurysms. However, in patients with multiple aneurysms secondary to MALS, arterial reconstruction may be considered prior to performing an endovascular procedure to restore physiological blood flow in the visceral circulation.