Median arcuate ligament syndrome confirmed with the use of intravascular ultrasound

Abstract

Median arcuate ligament syndrome, a rarely reported condition, is characterized by postprandial abdominal pain, nausea, vomiting, and weight loss. Its cause is unclear. We present the case of a 45-year-old woman who had intermittent chronic positional abdominal pain without weight loss. Magnetic resonance angiograms and computed tomograms revealed stenosis of the celiac artery. Ostial compression was confirmed on catheter angiographic and intravascular ultrasonographic images. Intravascular ultrasound revealed far greater stenosis than did the initial imaging methods and confirmed a diagnosis of median arcuate ligament syndrome. In lieu of surgery, the patient underwent a celiac ganglion block procedure that substantially relieved her symptoms. To our knowledge, this is the first report of the use of intravascular ultrasound in the diagnosis of median arcuate ligament syndrome. We recommend using this imaging method preoperatively in other suspected cases of the syndrome, to better identify patients who might benefit from corrective surgery.

Fig. 1

Axial computed tomographic angiogram from February 2011 shows narrowing of the proximal celiac artery.

Fig. 2

Angiograms show a multipurpose catheter engaging the celiac artery via radial access. Ostial compression was evident in the celiac artery and worsened upon expiration. A) There is tenting of the celiac artery upon inspiration, with a patent vessel. B) During the expiratory phase, apparent compression of the celiac artery causes severe stenosis.

Fig. 3

Intravascular ultrasonographic images of the celiac artery show A) the distal reference portion of the celiac artery; B) proximal hypoplasia of the celiac vessel with no intimal plaque, and hyperechoic fibrous tissue in the adventitia (right lower quadrant of image); and C) 72.2% luminal narrowing.