Median Arcuate Ligament Syndrome: Vascular Surgical Therapy and Follow-up of 18 Patients

      Conclusion: Open surgical therapy is safe and reliable for treatment of median arcuate ligament syndrome.
      Summary: Fixed stenosis and intermittent compression of the celiac artery are both common. Median arcuate ligament syndrome is characterized by a combination of extrinsic compression of the celiac artery from median arcuate ligament fibrous bands or ganglionic periaortic tissue, or both, in combination with abdominal pain, nausea, vomiting, and nonintentional weight loss. It is an infrequent diagnosis. The incidence of median arcuate ligament syndrome is estimated at 2 per 100,000 patients and is said to primarily affect asthenic young women. This article is a retrospective study of 18 patients (15 women, 3 men) treated for median arcuate syndrome at the authors' institution. Their median age was 46.2 years. The diagnosis was made by a combination of abdominal symptoms and radiologic demonstration of anterior compression of the celiac artery on angiography. All 18 patients were treated by open operation with decompression of the celiac access, but 11 patients also underwent additional vascular reconstruction of the celiac access for fixed narrowing of the celiac access. Three patients in this series also had treatment of superior mesenteric artery stenosis. After the primary operation, 28% underwent some type of revision procedure. Follow-up was possible in 15 patients, with a mean duration of 3.5 years after surgery. At the end of their follow-up, 11 of the 15 patients (73.33%) were free of abdominal symptoms.
      Comment: Flow in the celiac artery does not increase significantly with eating owing to the high fixed metabolic requirements of the liver and spleen. It is therefore unclear why postprandial pain should be ascribed as a feature of celiac access compression. The authors point out that if one is going to operate for a diagnosis of celiac axis compression, one should be prepared to perform some sort of intervention on the celiac artery itself. In many cases there is a fixed narrowing of the celiac artery, and if the goal of the surgery is to relieve narrowing of the celiac artery, it is very likely that some sort of reconstruction of the celiac axis will be required in addition to incising the overlying diaphragmatic and ganglionic tissue. The article doesn't really help us with the primary question of how to select patients for surgery. A description of the patients the authors chose not to intervene on would have been just as useful, or perhaps more useful, as the description of their operative techniques and results.