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Purpose: This study aimed to assess the safety and efficacy of endovascular treatment of unruptured pancreatic arcade aneurysms in a single-center series. Materials and Methods: The electronic medical records of patients who underwent endovascular treatment for unruptured pancreatic arcade aneurysms between 2011 and 2022 at our tertiary center were retrospectively reviewed. The presence of celiac artery stenosis/occlusion; aneurysm number, location, and size; endovascular technique; procedure-related complication incidence; and clinical outcomes were assessed. Results: Twenty-three patients (12 men and 11 women; mean [range] age, 63.8 [45–84] years) with 33 unruptured pancreatic arcade aneurysms were identified. Celiac artery stenosis/occlusion coexisted in 17 (74%) patients. Five (21%) patients had multiple aneurysms. The median aneurysm size was 9.3 mm (range, 4–18 mm). Seven, 6, 6, 5, 4, 3, and 2 aneurysms were located in the gastroduodenal, dorsal pancreatic, anterior superior pancreaticoduodenal, inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal, posterior superior pancreaticoduodenal, and anterior inferior pancreaticoduodenal arteries, respectively. Four (15%) and 22 (85%) aneurysms were treated with endosaccular packing alone and coil embolization with endosaccular packing and parent artery occlusion, respectively, with resulting exclusion from arterial circulation. The remaining 7 aneurysms coexisting with larger aneurysms in other peripancreatic arteries were observed without embolization because they were small and for preserving collateral blood flow to the celiac artery. The treated aneurysms did not rupture or recur during the follow-up period (median, 40 months). Conclusion: Endovascular treatment is a safe and effective treatment for unruptured pancreatic arcade aneurysms. Level of Evidence: 3, non-controlled retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Sutton–Kadir syndrome describes a rare pathology that commonly includes an aneurysm of the inferior pancreaticoduodenal artery in combination with a celiac trunk stenosis or occlusion, often caused by median arcuate ligament compression. Several therapeutic approaches exist including open surgical, endovascular, and hybrid treatments. Other combinations of visceral artery aneurysms and upstream stenoses exist but the cumulative body of evidence on these combinations is weak due to their rarity. Methods: A retrospective analysis of patient data from a single center was carried out. Electronic patient records were filtered for keywords including "visceral aneurysm", "Sutton–Kadir", and "median arcuate ligament". Imaging studies were re-examined by two blinded vascular surgeons with a third vascular surgeon as a referee in case of diverging results. Results: Sixteen patients had a visceral artery aneurysm with an upstream stenosis. All cases had a celiac trunk obstruction while one patient also had a concomitant superior mesenteric artery stenosis. Both median arcuate ligament compression and atherosclerotic lesions were identified. The location of the aneurysms varied even though the inferior pancreaticoduodenal artery was most frequently affected. A classification system based on the different combinations of stenoses and aneurysms is presented and introduced as a new pathologic entity: visceral artery aneurysm in the presence of upstream stenosis (VAPUS). Conclusions: The concomitant presence of visceral artery aneurysms, especially in the pancreaticoduodenal arteries, and blood flow impairment of the celiac axis or superior mesenteric artery is a rare pathology. The proposed VAPUS classification system offers an accessible and transparent route to the precise localization of the affected vessels. [ABSTRACT FROM AUTHOR]

The arc of Riolan (AoR), a marginal vessel in the left colon, interconnects the superior and inferior mesenteric arteries. A 65-year-old woman presented with an incidental aneurysmal lesion in the left upper abdomen found on ultrasound. Computed tomography revealed a 27-mm saccular aneurysm in the AoR with occlusion of the celiac artery and severe stenosis of the superior mesenteric artery. Angiography showed that the inferior mesenteric artery provided blood to the perfusion areas of the superior mesenteric artery, celiac artery, and left colon via the AoR. We performed open surgical repair of the aneurysm and reconstruction of the inferior mesenteric artery.

Introduction: Sutton–Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. Methods: A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. Results: Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. Conclusion: Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings. [ABSTRACT FROM AUTHOR]

This study was designed to reveal the association between spinal parameters and RCS area in patients with adult spinal deformities treated with spinal correction surgery. We hypothesized that reduction of the retrocrural space (RCS) area is related to thoracolumbar alignment, which may cause acute celiac artery compression syndrome (ACACS). Eighty-nine patients (age: 68.4 ± 7.6 years; sex: 7 male/82 female) with ASD treated by spinal correction surgery were enrolled. Preoperative and postoperative spinal parameters were measured, and the differences between these parameters were calculated. Postoperative T12 translation was measured and RCS area was evaluated using reconstructed computed tomography. The change of RCS area after surgery was defined as ΔRCS. Patients were divided into increased and decreased RCS groups by the ΔRCS value, and spinal parameters were compared between groups. The correlation between spinal parameters and ΔRCS was calculated. The patients in the decreased RCS group had greater anterior T12 translation than those in the increased RCS group (p < 0.001). T12 translation was significantly correlated with ΔRCS (β = −0.31, p = 0.017). There were no correlations between ΔRCS and other spinal parameters. Thoracolumbar alignment was associated with RCS area. Consistent with the hypothesis, overcorrection of the thoracolumbar junction was associated with reduced RCS area and might be one risk factor for ACACS. [ABSTRACT FROM AUTHOR]

This study aimed to characterize the anatomical relationship between the spine, the celiac artery (CA), and the median arcuate ligament using preoperative contrast-enhanced computed tomography (CT) images of patients with spinal deformity who underwent surgical correction. This retrospective study included 81 consecutive patients (34 males, 47 females; average age: 70.2 years). The spinal level at which the CA originated, the diameter, extent of stenosis, and calcification were determined using CT sagittal images. Patients were divided into two groups: CA stenosis group and non-stenosis group. Factors associated with stenosis were examined. CA stenosis was observed in 17 (21%) patients. CA stenosis group had significantly higher body mass index (24.9 ± 3.9 vs. 22.7 ± 3.7, p = 0.03). In the CA stenosis group, J-type CA (upward angling of the course by more than 90° immediately after descending) was more frequently observed (64.7% vs. 18.8%, p < 0.001). The CA stenosis group had lower pelvic tilt (18.6 ± 6.7 vs. 25.1 ± 9.9, p = 0.02) than non-stenosis group. High BMI, J-type, and shorter distance between CA and MAL were risk factors for CA stenosis in this study. Patients with high BMI undergoing fixation of multiple intervertebral corrective fusions at the thoracolumbar junction should undergo preoperative CT evaluation of the anatomy of CA to assess the poteitial risk of celiac artery compression syndrome. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to determine whether the proximity of the median arcuate ligament (MAL) and the celiac artery (CA) changes in patients following surgery to correct adult spinal deformity (ASD). We hypothesized that the distance between the MAL and the CA shortens after corrective spinal surgery, which may cause acute celiac artery compression syndrome (ACACS). Methods: A total of 89 patients (68.4±7.6 years; 7 men/82 women) with ASD treated with spinal correction surgery were included in the present retrospective study. The level of the MAL, CA, and distance between the MAL and the CA (DMC) were determined via reconstructed computed tomography. MAL overlap was determined preoperatively and postoperatively. Results: The MAL and CA moved caudally following surgery. On average, after surgery, no changes in DMC were observed. We found preoperative MAL overlap in 32 (36%) patients, who also had postoperative MAL overlap. No patients showed any MAL overlap postoperatively. Conclusions: Contrary to our hypothesis, the distance between the MAL and the CA did not shorten, and emerging MAL overlap was not observed postoperatively.

Median arcuate ligament syndrome (MALS) is characterized by the constriction of the celiac trunk caused by fibrous connections originating from the median arcuate ligament (MAL) and diaphragmatic crura. It presents with symptoms often leading to misdiagnosis. In this study, we present three cases of MALS, with distinct manifestations. These cases were diagnosed through comprehensive investigations and managed successfully using laparoscopic decompression. The diagnosis of MALS poses challenges due to its variable presentations and overlap with other conditions. Diagnostic imaging techniques such as Doppler ultrasound, computed tomography (CT) scans and angiography play a role in confirming the diagnosis. Laparoscopic decompression has proven to be a treatment option that relieves symptoms and restores blood flow. This series highlights the importance of considering MALS as a cause for abdominal pain cases. Early detection and the use of diagnostic techniques can result in favorable outcomes. [ABSTRACT FROM AUTHOR]

Background: Ischemic necrosis of the abdominal organs caused by compression of the celiac artery (CA) and superior mesenteric artery (SMA) by the median arcuate ligament (MAL) after correction surgery has been recognized as acute celiac artery compression syndrome (ACACS). Here, using contrast-enhanced computed tomographic (CT) images, we sought to determine the prevalence and degree of CA and SMA stenosis in spinal patients preoperatively, and the risk factors associated with the stenosis.Methods: We retrospectively examined contrast-enhanced abdominal CT of 90 patients with preoperative lumbar degenerative disease, lumbar burst fracture, or adult spinal deformity. The trunks of the CA and SMA were detected using three-dimensional reconstructed CT. To investigate their degree of stenosis, we determined the ratio of the narrowest diameter of the stenotic segment to the distal normal lumen's diameter. Patients with a degree of stenosis ≥35% were defined as being in the group with stenosis and the remainder as in the group without. To determine the risk factors for stenosis of these arteries, the relationship between the stenosis and CA and SMA calcification or the median arcuate ligament (MAL) crossing the proximal portion of the celiac axis (MAL overlap) was also investigated.Results: The average degree of stenosis of the CA trunk was 12.1% ± 13.9% and that for the SMA trunk was 8.5% ± 8.8%. There were 8 patients (8.9%) in the group with CA stenosis and 2 patients (2.2%) in the group with SMA stenosis. The number of patients in the group with CA stenosis was significantly greater than the number with MAL overlap or CA calcification (P < 0.05).Discussion: The prevalence of CA or SMA stenosis was 11.2% of preoperative patients due to undergo thoracolumbar fusion surgery. Calcifications of the CA trunk and MAL overlap are risk factors for CA stenosis. [ABSTRACT FROM AUTHOR]

Median arcuate ligament (MAL) syndrome (MALS) is a rare condition caused by compression of the celiac artery by the MAL. Symptoms include abdominal pain, nausea, and weight loss. Rarely, the MAL can compress both the celiac artery and the superior mesenteric artery (SMA). We describe the case of a young man with MALS involving the celiac artery and SMA. Laparoscopic release of the MAL was performed, and the patient had resolution of his symptoms at 6 months of follow-up. A review of the literature identified only six cases of MALS involving the SMA and celiac artery, making this a rare occurrence.

This article explores the CT findings and outcome of a case involving median arcuate ligament compression syndrome complicated with spontaneous isolated superior mesenteric artery dissection. Three-dimensional reconstruction of multi-detector spiral CT angiography can effectively display the degree of abdominal trunk stenosis, development of collateral circulation, and dynamic process of superior mesenteric artery dissection remodeling. This approach is valuable for evaluating the disease and guiding the clinical treatment.

Background: Median Arcuate L igament S yndrome ( MALS) i s a r are clinical condition w ith a r ate o f 2/100000 in the society. Therefore, MALS cases are diagnosed late.In this article, we aimed to present the findings of five patients who were diagnosed with MALS in our clinic and underwent surgical treatment, in the light of the literature. Materials and Methods: The files of five patients who were diagnosed with MALS and underwent surgical treatment in our clinic between January 2021 and December 2022 were reviewed retrospectively and data were obtained. Results: Five patients who received surgical treatment with the diagnosis of MALS were identified. Three of the patients w ere woman and two were man. All patients complained of weight loss and i ncreased abdominal pain after meals. It was observed the patients gained weightin the ±13,2 (3-24) month followup period after the surgical treatment. In addition, it was determined that his clinical complaints were resolved. Conclusions: Although MALS is a rare disease, it is important because of delay in diagnosis and treatment, loss of workforce and increasing costs on the health system due to chronic complaints of patients. Surgical excision of the fibrous band thst causes the pressure, is very effective in relieving the complaints. [ABSTRACT FROM AUTHOR]

Transarterial embolization (TAE) for high-flow pancreaticoduodenal artery (PDA) aneurysms in patients with celiac-trunk stenosis by the median arcuate ligament (MAL) has been found effective both after rupturing and to prevent rupture. The objective was to describe the TAE techniques used and their effectiveness in excluding PDA aneurysms due to MAL syndrome. This single-center retrospective study done at the Dijon-Bourgogne University Hospital included all patients treated by TAE in 2010–2022 for ruptured or unruptured high-flow PDA aneurysms caused by MAL syndrome. We identified 14 patients (7 women and 7 men; mean age, 64 years). Packing and trapping techniques were used alone or together. Occlusion was with microcoils, co-polymer, or cyanoacrylate glue, used separately or combined. Technical success was achieved in 13 (93%) patients. Clinical success was achieved in 12 (86%) patients. One major and two minor complications were recorded within the first 30 days. No complications occurred after 30 days. Follow-up ranged from 1 to 84 months. No cases of aneurysm recanalization have been recorded to date. TAE had high technical and clinical success rates in our patients with unruptured or ruptured PDA aneurysms due to MAL syndrome. [ABSTRACT FROM AUTHOR]

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Background: Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. Methods: This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. Results: A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. Conclusions: Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Mesenteric ischemia is a serious medical condition characterized by insufficient vascular supply to the small bowel. In the acute setting, endovascular interventions, including embolectomy, transcatheter thrombolysis, and angioplasty with or without stent placement, are recommended as initial therapeutic options. For nonocclusive mesenteric ischemia, transarterial infusion of vasodilators, such as papaverine or prostaglandin E1, is the recommended initial treatment. In the chronic setting, endovascular means of revascularization, including angioplasty and stent placement, are generally recommend, with surgical options, such as bypass or endarterectomy, considered alternative options. Although the diagnosis of median arcuate ligament syndrome remains controversial, diagnostic angiography can be helpful in rendering a diagnosis, with the preferred treatment option being a surgical release. Systemic anticoagulation is recommended as initial therapy for venous mesenteric ischemia with acceptable rates of recanalization. If anticoagulation fails, transcatheter thrombolytic infusion can be considered with possible adjunctive placement of a transjugular intrahepatic portosystemic shunt to augment antegrade flow. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

To evaluate the impact of celiac artery (CA) compression by median arcuate ligament (MAL) on technical metrics and long-term CA patency in patients with complex aortic aneurysms undergoing fenestrated/branched endograft repairs (F/B-EVARs). Single-center, retrospective review of patients undergoing fenestrated/branched endovascular aortic aneurysm repairs and requiring incorporation of the CA between 2013 and 2023. Patients were divided into two groups—those with (MAL+) and without (MAL−) CA compression—based on preoperative computed tomography angiography findings. MAL was classified in three grades (A, B, and C) based on the degree and length of stenosis. Patients with MAL grade A had ≤50% CA stenosis measuring ≤3 mm in length. Those with grade B had 50% to 80% CA stenosis measuring 3 to 8 mm long, whereas those with grade C had >80% stenosis measuring >8 mm in length. End points included device integrity, CA patency and technical success—defined as successful implantation of the fenestrated/branched device with perfusion of CA and no endoleak. One hundred and eighty patients with complex aortic aneurysms (pararenal, 128; thoracoabdominal, 52) required incorporation of the CA during fenestrated/branched endovascular aortic aneurysm repair. Majority (73%) were male, with a median age of 76 years (interquartile range [IQR], 69-81 years) and aneurysm size of 62 mm (IQR, 57-69 mm). Seventy-eight patients (43%) had MAL+ anatomy, including 33 patients with MAL grade A, 32 with grade B, and 13 with grade C compression. The median length of CA stenosis was 7.0 mm (IQR, 5.0-10.0 mm). CA was incorporated using fenestrations in 177 (98%) patients. Increased complexity led to failure in CA bridging stent placement in four MAL+ patients, but completion angiography showed CA perfusion and no endoleak, accounting for a technical success of 100%. MAL+ patients were more likely to require bare metal stenting in addition to covered stents (P =.004). Estimated blood loss, median operating room time, contrast volume, fluoroscopy dose and time were higher (P <.001) in MAL+ group. Thirty-day mortality was 3.3%, higher (5.1%) in MAL+ patients compared with MAL− patients (2.0 %). At a median follow-up of 770 days (IQR, 198-1525 days), endograft integrity was observed in all patients and CA events—kinking (n = 7), thrombosis (n = 1) and endoleak (n = 2) —occurred in 10 patients (5.6%). However, only two patients required reinterventions. MAL+ patients had overall lower long-term survival. CA compression by MAL is a predictor of increased procedural complexity during fenestrated/branched device implantation. However, technical success, long-term device integrity and CA patency are similar to that of patients with MAL− anatomy. [ABSTRACT FROM AUTHOR]

Abstract Background The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor–Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release. Case presentation A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter. Conclusions Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.

Dunbar syndrome (DS) (or median arcuate ligament [MAL] syndrome) is a rare entity of the vascular compression syndrome, where there is focal proximal coeliac axis compression by MAL. It results in an insufficient supply of blood to the respective organs of the gastrointestinal tract. Multidetector computed tomography is a very convenient, noninvasive modality in diagnosing this condition and helpful in distinguishing it from other conditions, such as atherosclerotic disease. DS can further be treated disorder surgically by relieving the compression and sometimes may need vascular reconstruction. We present five cases of the DS.

Introduction: The presence of median arcuate ligament (MAL) during orthotopic liver transplantation (OLT) may cause a significant reduction in the arterial hepatic flow. The aim of the present study is to investigate the impact of MAL on biliary complications in patients who underwent OLT. Methods: We performed a retrospective case‐control study among patients who underwent OLT in Geneva University Hospital between 2007 and 2017, depending on the presence or absence of MAL. The matching was performed according to age, gender, lab‐MELD score at the time of OLT and type of donor (living or dead). The presence of MAL was assessed by an expert liver radiologist on the preoperative CT angiographic evaluation. Results: The incidence of MAL was 6.1% (19 patients). Baseline characteristics were comparable between the two groups. No significant difference in biliary complications was found between patients with and without MAL (37% and 24%, respectively). No patient presented hepatic artery thrombosis. After logistic regression, in patients with MAL, the MAL release and gastroduodenal artery preservation compared to no treatment, showed an odds ratio for post‐OLT biliary complications of 1.5 and 1.25, respectively. There was no difference in overall graft survival and in hazard for biliary complications between patients with and without MAL. Conclusion: In the present study, we did not find any difference in the prevalence of biliary and arterial complications between patients with and without MAL. The choice of MAL treatment did not influence in a significant way the overall outcome and development of complications. However, if, at the end of arterial reconstruction, the arterial flow is not adequately established, MAL needs to be treated with the least invasive technique. [ABSTRACT FROM AUTHOR]

Flexible esophagogastroduodenoscopy is the gold standard for the management of acute upper gastrointestinal bleeding. This is a case of a man who was admitted in the emergency department because of melena with hypotension because of an ulcer in the anterior face of the duodenal bulb, refractory to 3 attempts of endoscopic therapy. Then, a gastroduodenal arterial embolization was tried, being impossible because of the presence of the median arcuate ligament, compressing the celiac trunk. A balloon-expandable stent was inserted in the celiac trunk, and then, the embolization was performed. After unsuccessful endoscopic management, the arterial embolization is one of the treatment options in nonvariceal acute upper gastrointestinal bleeding., (© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Abstract 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.

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: The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor–Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release. Case presentation: A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter. Conclusions: Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy. [ABSTRACT FROM AUTHOR]

Dunbar syndrome (DS) (or median arcuate ligament [MAL] syndrome) is a rare entity of the vascular compression syndrome, where there is focal proximal coeliac axis compression by MAL. It results in an insufficient supply of blood to the respective organs of the gastrointestinal tract. Multidetector computed tomography is a very convenient, noninvasive modality in diagnosing this condition and helpful in distinguishing it from other conditions, such as atherosclerotic disease. DS can further be treated disorder surgically by relieving the compression and sometimes may need vascular reconstruction. We present five cases of the DS. [ABSTRACT FROM AUTHOR]

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.

Dunbar syndrome, also known as median arcuate ligament syndrome, is a rare clinical condition due to the external compression of the celiac trunk by the median arcuate ligament causing abdominal angina. We report a case of Dunbar syndrome and its borderline imaging findings focused on the crucial diagnostic role of color-Doppler ultrasound. We also reviewed the current literature, delineating the clinical manifestations and the diagnostic workup of the Dunbar syndrome with the objective to increase the knowledge of this clinical entity as a cause of postprandial abdominal pain and to underline the pivotal role of color-Doppler ultrasound to avoid incorrect or delayed diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: 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. Methods: 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. Conclusion: This report presents the detailed anatomy and procedural steps for CA decompression in MAL syndrome. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 at < 48 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. [Display omitted] [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

• 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. 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. 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. 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. Laparoscopic release of celiac artery compression is a safe and effective method to treat this uncommon disease. [ABSTRACT FROM AUTHOR]

The median arcuate ligament, or celiac artery compression syndrome is a rare syndrome, caused by extrinsic compression of the celiac trunk by the median arcuate ligament. Its symptomatology mainly comprises of visceral angina. Differential diagnosis includes cardiovascular angina, other vascular events and causes of vagotonia. The case reported here refers to a middle aged male patient who presented with intermittent epigastric pain and diaphoresis after a long drive. Diagnosis was made radiologically, during computed tomography scan angiography, which revealed a hook-like appearance of the celiac artery partially loosened during inspiration. Careful history and cautious reviewing of the imaging may refrain from further, unnecessary, diagnostic investigations.

Abstract Background Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow. Case presentation A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications. Conclusion The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.

The Median Arcuate Ligament (MAL) syndrome is the symptomatic compression of the celiac trunk by the MAL and other ganglionic periaortic tissue. Despite its rarity, this condition is significant from a clinical, diagnostic and management standpoint and it is usually a diagnosis of exclusion. A 61-year-old female with history of intermittent postprandial epigastric pain was diagnosed with MAL syndrome during CT scan imaging (no other causes of pain were identified). Patient successfully underwent robotic MAL release with symptoms improvement after surgery. The robotic approach is feasible and may allow a very precise and delicate dissection with release of the MAL. [ABSTRACT FROM AUTHOR]

Celiac artery compression syndrome (CACS), also known as Dunbar syndrome or median arcuate ligament syndrome (MALS), is a condition that can result from a fibrous ligament, the median arcuate ligament, passing superior to the celiac axis causing extrinsic compression or entrapment of sympathetic neural fibers near its takeoff from the abdominal aorta. This uncommon disorder is characterized clinically by the triad of postprandial abdominal pain, weight loss, and sometimes abdominal bruit. In the literature, most cases of CACS are from Western countries. The diagnosis is generally considered after more common conditions have been ruled out. In particular, an extensive evaluation of GI tract and biliary system have been done in an effort to identify the cause of pain. For patients in whom celiac artery compression is suspected, the diagnosis requires vascular imaging with a respiratory maneuver to confirm CACS. The author reported a 27-year-old woman with CACS, along with results of cross-sectional CTA, 3D reconstruction, combined with intra-operative duplex ultrasound of the celiac artery to demonstrate stenosis, and an attempt at decompression by aggressive resection of median arcuate ligament and nerve fibers. [ABSTRACT FROM AUTHOR]

• 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. 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. 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. 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. Vascular disorders should be investigated in cases of abdominal pain after complex surgical procedures. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The arc of Riolan (AoR), a marginal vessel in the left colon, interconnects the superior and inferior mesenteric arteries. A 65-year-old woman presented with an incidental aneurysmal lesion in the left upper abdomen found on ultrasound. Computed tomography revealed a 27-mm saccular aneurysm in the AoR with occlusion of the celiac artery and severe stenosis of the superior mesenteric artery. Angiography showed that the inferior mesenteric artery provided blood to the perfusion areas of the superior mesenteric artery, celiac artery, and left colon via the AoR. We performed open surgical repair of the aneurysm and reconstruction of the inferior mesenteric artery., Competing Interests: None., (© 2024 Published by Elsevier Inc. on behalf of Society for Vascular Surgery.)

Background: Due to the rarity of median arcuate ligament (MAL) syndrome, patient selection for surgery remains difficult. This study provides a predictive model to optimize patient selection and predict outcomes following a MAL release.Methods: Prospective data from patients undergoing a MAL release included demographics, radiologic studies, and SF-36 questionnaires. Successful postoperative changes in SF-36 was defined as an improvement > 10% in the total SF-36 score. A logistic regression model was used to develop a clinically applicable table to predict surgical outcomes. Celiac artery (CA) blood flow velocities were compared pre- and postoperatively and Pearson correlations were examined between velocities and SF-36 score changes.Results: 42 patients underwent a laparoscopic MAL release with a mean follow-up of 28.5 ± 18.8 months. Postoperatively, all eight SF-36 scales improved significantly. The logistic regression model for predicting surgical benefit was significant (p = 0.0244) with a strong association between predictors and outcome (R2 = 0.36). Age and baseline CA expiratory velocity were significant predictors of improvement and predicted clinical improvement. There were significant differences between pre- and postoperative CA velocities. Postoperatively, the bodily pain scale showed the most significant increase (64%, p < 0.0001). A table was developed using age and preoperative CA expiratory velocities to predict clinical outcomes.Conclusions: Laparoscopic MAL produces significant symptom improvement, particularly in bodily pain. This is one of the first studies that uses preoperative data to predict symptom improvement following a MAL release. Age and baseline CA expiratory velocity can be used to guide postoperative expectations in patients with MAL syndrome. [ABSTRACT FROM AUTHOR]

Abstract Objective The increasing use of computed tomography (CT) angiography has led to more frequent diagnoses of celiac artery compression (CAC) by the median arcuate ligament (MAL). The signs of CAC by the MAL have been described as stenosis and a hook or J appearance on sagittal views. The importance of the "hook signal," however, has not been documented by studies of the normal anatomy of the celiac axis. Methods CT angiography images of 344 completely asymptomatic, live kidney donors (without history of chronic abdominal pain or weight loss) were reviewed. The angle of emergence (AE) of the celiac axis from the aorta and the angle of upward or downward shifting of the celiac axis before its first branch (fold angle [FA]) were measured. Weight, height, and body mass index were obtained from our electronic database, and correlations with the angles measured were tested. The occurrence of stenosis >50% at the origins of the celiac axis was also determined in the sample. Results Measurements were possible in 321 cases. The celiac axis was found to leave the aorta at an angle of <90 degrees in all patients (AE range, 7-83 degrees) and <45 degrees in 292 (90%) patients. The FA ranged from 66 to 208 degrees. Before the first branch, the celiac trunk shifted upward in 306 (95%) patients, remained straight in just one of them, and shifted downward in 14 (4%). The AE was positively correlated with weight in women. The FA was negatively correlated with weight in men and women. Body mass index was positively correlated with AE and negatively correlated with FA in both men and women. In 11 cases (3.4%), stenosis >50% was found at the origin of the celiac axis. In only two patients, the celiac axis had an upward slope after the stenosis, which could be interpreted as a hook shape. Conclusions The normal anatomy of the celiac axis, when seen on CT angiography images, demonstrates that it exits the aorta downward and then shifts upward. This hook or J shape should not be interpreted as resulting from external compression. CAC by the MAL occurs in 3.42% of the normal asymptomatic population; a hook or J shape is not visible in most cases in that subgroup. [ABSTRACT FROM AUTHOR]