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Arino H, Wada M, Kobayashi H, Yoshida A, Oka S, Inokuma T. Metachronous Rupture of Pancreatoduodenal Artery Aneurysm with Median Arcuate Ligament Syndrome: A Case Report and Review of 11 Cases. Intern Med 2025; 64:665-671. [PMID: 39135259 PMCID: PMC11949662 DOI: 10.2169/internalmedicine.3338-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 06/16/2024] [Indexed: 03/04/2025] Open
Abstract
Median arcuate ligament syndrome (MALS) involves narrowing of the celiac artery root from MAL compression, leading to pancreatoduodenal artery aneurysm (PDAA) due to increased retrograde blood flow from the superior mesenteric artery into the PDA. We encountered a case in which coil embolization was performed for PDAA rupture due to MALS. Four years later, a second PDAA occurred and ruptured, necessitating coil reembolization. There have been no reports of recurrence during long-term follow-up after PDAA treatment in patients with MALS. We herein report a rare case of metachronous PDAA rupture in the context of MALS. The relevant literature and 11 PDAA/MALS cases are discussed.
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Affiliation(s)
- Hiroto Arino
- Department of Gastroenterology, Kobe City Medical Center General Hospital, Japan
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Masaya Wada
- Department of Gastroenterology, Kobe City Medical Center General Hospital, Japan
| | | | - Atsushi Yoshida
- Department of Radiology, Kobe City Medical Center General Hospital, Japan
| | - Shojiro Oka
- Department of Radiology, Kobe City Medical Center General Hospital, Japan
| | - Tetsuro Inokuma
- Department of Gastroenterology, Kobe City Medical Center General Hospital, Japan
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Emekli E, Bayav FD, Gündoğdu E. Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study. Surg Radiol Anat 2024; 46:805-810. [PMID: 38622333 DOI: 10.1007/s00276-024-03352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/18/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.
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Affiliation(s)
- Emre Emekli
- Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey.
| | - Fatma Didem Bayav
- Department of Radiology, Karadeniz Ereğli State Hospital, Zonguldak, Turkey
| | - Elif Gündoğdu
- Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
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Sugaya T, Suzuki T, Wada J, Shimizu H, Uchihara D, Yokogawa Y, Ichii O, Tai M, Ejiri Y, Ohira H. Transarterial embolization for ruptured pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis combined with median arcuate ligament syndrome: a case report. Clin J Gastroenterol 2023; 16:859-863. [PMID: 37608145 DOI: 10.1007/s12328-023-01847-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
A 75-year-old female with a history of Parkinson's disease treatment and hypertension presented at the emergency section with sudden onset of right abdominal pain. Contrast-enhanced computed tomography revealed beaded irregular stenosis and dilation of the superior mesenteric artery (SMA) and an aneurysm in the branch of the pancreaticoduodenal artery (PDA) that communicates with the common hepatic artery and SMA. Additionally, a hematoma had formed in the retroperitoneal space, and extravasation of contrast medium from the pancreaticoduodenal artery aneurysm (PDAA) into the hematoma was observed. The celiac artery (CA) was compressed by the median arcuate ligament; stenosis of the CA at its origin and dilation on the distal side were observed. Based on the imaging findings, it was diagnosed that PDAA was ruptured, SMA developed segmental arterial mediolysis (SAM), and CA developed median arcuate ligament syndrome (MALS). The ruptured PDAA was thought to be caused by SAM combined with MALS. Transcatheter arterial embolization (TAE) was performed for the ruptured PDAA. To the best of our knowledge, there have been no reports of TAE for a ruptured PDAA caused by SAM and MALS. After TAE, the PDAA did not re-rupture.
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Affiliation(s)
- Tatsuro Sugaya
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan.
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Tomohiro Suzuki
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Jun Wada
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroshi Shimizu
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Daiki Uchihara
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yuko Yokogawa
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Osamu Ichii
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Mayumi Tai
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Yutaka Ejiri
- Department of Gastroenterology, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Braet DJ, Pourak K, Davis FM, Eliason JL, Vemuri C. Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk. J Vasc Surg Cases Innov Tech 2023; 9:101348. [PMID: 37965115 PMCID: PMC10641679 DOI: 10.1016/j.jvscit.2023.101348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/21/2023] [Indexed: 11/16/2023] Open
Abstract
Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.
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Affiliation(s)
- Drew J. Braet
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kian Pourak
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Frank M. Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan L. Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Chandu Vemuri
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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Makazu M, Koizumi K, Masuda S, Jinushi R, Shionoya K, Tsukiyama T. Spontaneous retroperitoneal hematoma with duodenal obstruction with diagnostic use of endoscopic ultrasound: A case series and literature review. Clin J Gastroenterol 2023; 16:377-386. [PMID: 36959407 DOI: 10.1007/s12328-023-01780-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/26/2023] [Indexed: 03/25/2023]
Abstract
Spontaneous retroperitoneal hematoma is rare and can cause duodenal obstruction. We report four cases of spontaneous retroperitoneal hematoma with duodenal obstruction, wherein endoscopic ultrasound was useful for diagnosis. The patients complained of vomiting with stable vital signs. Computed tomography, esophagogastroduodenoscopy, and endoscopic ultrasound findings were similar in all cases. Contrast-enhanced computed tomography revealed a low-density mass around the 2nd to 3rd part of the duodenum. Esophagogastroduodenoscopy showed an edematous, reddish, but non-neoplastic duodenal mucosa with stenosis of the lumen. Endoscopic ultrasound revealed a low-echoic mass around the duodenum and high-echoic floating matter suggesting debris and anechoic areas that indicated a liquid component. These findings suggested hematomas or abscesses. Although pseudoaneurysm of the pancreaticoduodenal artery was suspected in Case 3, we chose conservative treatment because the aneurysm was small. In Case 4, median arcuate ligament syndrome was suspected on angiography. No aneurysms or arteriovenous malformations were found; thus, endovascular embolization was not performed. The patients were treated conservatively and discharged within 3-5 weeks. English literature queries on spontaneous retroperitoneal hematoma with duodenal obstruction in MEDLINE revealed 21 cases in 18 studies. The clinical features of these patients and the present four cases have been discussed.
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Affiliation(s)
- Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Ryuhei Jinushi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kento Shionoya
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Toshitaka Tsukiyama
- Interventional Radiology Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Shimbara K, Shintakuya R, Honmyo N, Nakagawa N, Kohashi T. Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report. Int J Surg Case Rep 2023; 106:108041. [PMID: 37030161 PMCID: PMC10119882 DOI: 10.1016/j.ijscr.2023.108041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection. CASE PRESENTATION A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms. CLINICAL DISCUSSION MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS. CONCLUSION It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.
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Borges AP, Antunes C, Donato P. Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization. Abdom Radiol (NY) 2023; 48:1415-1428. [PMID: 36801957 PMCID: PMC10115732 DOI: 10.1007/s00261-023-03844-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/21/2023]
Abstract
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.
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Affiliation(s)
- Ana Paula Borges
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal.
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal.
| | - Célia Antunes
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
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Tan EWK, Shelat VG, Monteiro AY, Low JK. Spontaneous retroperitoneal haemorrhage from pancreatoduodenal artery (PDA) rupture and associated complications. BMJ Case Rep 2022; 15:e250383. [PMID: 36253011 PMCID: PMC9577903 DOI: 10.1136/bcr-2022-250383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/06/2022] Open
Abstract
Spontaneous retroperitoneal haemorrhage (SRH) is rare. It may present with abdominal or back pain with or without haemodynamic instability. Aggressive resuscitation while investigating the cause of bleeding and providing haemostasis are the standard of care. Subsequent close monitoring is necessary to identify early complications.This study reports three patients who presented to our institution within the last 5 years with SRH from a ruptured pancreaticoduodenal artery (PDA) aneurysm. Each patient had a unique presentation, complications and treatment demonstrating the variability and complexity of SRH. One patient presented with sudden abdominal pain and hypovolaemic shock, underwent angioembolisation and had an eventful recovery. Another patient presented similarly and was treated via angioembolisation but experienced gastric outlet obstruction and obstructive jaundice requiring surgical haematoma evacuation. Another patient had an incidental finding of haemoperitoneum during laparoscopic cholecystectomy that was subsequently diagnosed as SRH resulting from a PDA aneurysm rupture secondary to medial arcuate ligament syndrome.
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Affiliation(s)
- Edmund Wooi Keat Tan
- National Healthcare Group, Singapore
- Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G Shelat
- National Healthcare Group, Singapore
- Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Jee Keem Low
- National Healthcare Group, Singapore
- Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Singapore
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Lu XC, Pei JG, Xie GH, Li YY, Han HM. Median arcuate ligament syndrome with retroperitoneal haemorrhage: A case report. World J Clin Cases 2022; 10:7509-7516. [PMID: 36158028 PMCID: PMC9353894 DOI: 10.12998/wjcc.v10.i21.7509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is relatively rare and is due to extraluminal compression of the coeliac artery by the median arcuate ligament of the diaphragm. Here, we report a case of MALS found in a patient with abdominal pain and retroperitoneal haemorrhage for education and dissemination.
CASE SUMMARY This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.
CONCLUSION MALS is very rare and usually has postprandial abdominal pain, upper abdominal murmur, and weight loss. It is diagnosed by imaging or due to complications. When a patient has abdominal bleeding or PDAA, we should consider whether the patient has celiac trunk stenosis (MALS or other etiology). When abdominal bleeding is combined with an aneurysm, we generally think of aneurysm rupture and hemorrhage first, but it may also be collateral artery rupture and hemorrhage.
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Affiliation(s)
- Xiao-Chen Lu
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Jian-Guo Pei
- Department of Imaging, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Hua Xie
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Yong-Yu Li
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Hong-Mei Han
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
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Yoshimura Y, Sakamoto SI, Hiromoto A, Murata T, Suzuki K, Yasui D, Mizutani S, Ishii Y. A Case of Chronic Mesenteric Ischemia: Complete Revascularization Using Multiple Procedures. Ann Vasc Dis 2021; 14:407-410. [PMID: 35082952 PMCID: PMC8752926 DOI: 10.3400/avd.cr.21-00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Chronic mesenteric ischemia (CMI) involving occlusion and/or stenosis of multiple mesenteric arteries is rare. We report our experience with a 66-year-old man who presented with a more than 3 months history of abdominal pain and vomiting/diarrhea. A diagnosis of CMI due to occlusion of the superior mesenteric artery (SMA) and severe stenosis of the celiac artery by median arcuate ligament syndrome was made. Complete revascularization through iliac artery–SMA bypass grafting and arcuate ligament dissection assisted with staged-catheter intervention successfully alleviated the patient’s symptoms. The patient has maintained a normal daily diet for 6 months postoperatively.
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Affiliation(s)
- Yusuke Yoshimura
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Shun-Ichiro Sakamoto
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Atushi Hiromoto
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Tomohiro Murata
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Suzuki
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Daisuke Yasui
- Department of Radiology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Satoshi Mizutani
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
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El Hassani Y, Haloua M, Alami B, Boubbou M, Maaroufi M, Lamrani MYA. Imaging of retroperitoneal haemorrhage revealing median arcuate ligament syndrome. SA J Radiol 2021; 25:1993. [PMID: 33824741 PMCID: PMC8008131 DOI: 10.4102/sajr.v25i1.1993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/30/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Younes El Hassani
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
| | - Meriem Haloua
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
| | - Badreeddine Alami
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
| | - Meryem Boubbou
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
| | - Mustapha Maaroufi
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
| | - Moulay Youssef Alaoui Lamrani
- Department of Radiology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Hassan II University Hospital, Fez, Morocco
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12
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Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome). Ann Diagn Pathol 2021; 52:151732. [PMID: 33798927 DOI: 10.1016/j.anndiagpath.2021.151732] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m2. They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.
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Hanaki T, Sakamoto T, Yata S, Murakami Y, Fujiwara Y. Successful Interventional Radiology for Acute Median Arcuate Ligament Syndrome After Pancreaticoduodenectomy. Cureus 2021; 13:e13540. [PMID: 33796419 PMCID: PMC8006561 DOI: 10.7759/cureus.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Takehiko Hanaki
- Department of Gastroenterological Surgery, Tottori University, Faculty of Medicine, Yonago, JPN
| | - Teruhisa Sakamoto
- Department of Gastroenterological Surgery, Tottori University, Faculty of Medicine, Yonago, JPN
| | - Shinsaku Yata
- Division of Radiology, Tottori University, Faculty of Medicine, Yonago, JPN
| | - Yuki Murakami
- Department of Gastroenterological Surgery, Tottori University, Faculty of Medicine, Yonago, JPN
| | - Yoshiyuki Fujiwara
- Department of Gastroenterological Surgery, Tottori University, Faculty of Medicine, Yonago, JPN
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Kimura N, Matsui K, Shibuya K, Yoshioka I, Naruto N, Hoshino Y, Mori K, Hirano K, Watanabe T, Hojo S, Sawada S, Okumura T, Nagata T, Noguchi K, Fujii T. Metachronous rupture of a residual pancreaticoduodenal aneurysm after release of the median arcuate ligament: a case report. Surg Case Rep 2020; 6:34. [PMID: 32016595 PMCID: PMC6997311 DOI: 10.1186/s40792-020-0784-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Multiple pancreaticoduodenal artery aneurysms in association with median arcuate ligament syndrome (MALS) are relatively rare. A treatment option, such as a median arcuate ligament (MAL) release or embolization of the aneurysms, should be considered in such cases, but the treatment criteria remain unclear.
Case report
A 75-year-old man was transferred to our hospital because of a ruptured pancreaticoduodenal aneurysm. Emergency angiography showed stenosis of the root of the celiac axis (CA), a ruptured aneurysm of the posterior inferior pancreaticoduodenal artery (PIPDA), and an unruptured aneurysm of the anterior inferior pancreaticoduodenal artery (AIPDA). Coil embolization of the PIPDA was performed. Five days after embolization, the gallbladder became necrotic due to decreased blood flow in the CA region, and an emergency operation was performed. We performed a cholecystectomy and released the MAL to normalize the blood flow of the CA region. However, the patient died on postoperative day 8 because of rupture of the untreated aneurysm of the AIPDA.
Conclusions
This is the first report of metachronous ruptures of multiple pancreaticoduodenal aneurysms due to MALS, even after a MAL release. Although rare, a residual aneurysm in the pancreatic head region may need to be embolized quickly.
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