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Case Reports
. 2022 May 3;16(2):284-289.
doi: 10.1159/000524428. eCollection 2022 May-Aug.

Normalization of Flow in the Common Hepatic Artery after Decompression of Median Arcuate Ligament Syndrome with Diminution of a Pancreatoduodenal Arcade Aneurysm

Kenji Matsumoto  1   2 , Hiroharu Shinozaki  1 , Satoshi Shinozaki  3   4 , Toshiaki Terauchi  1 , Alan Kawarai Lefor  2 , Naohiro Sata  2
Affiliations
Case Reports

Normalization of Flow in the Common Hepatic Artery after Decompression of Median Arcuate Ligament Syndrome with Diminution of a Pancreatoduodenal Arcade Aneurysm

Kenji Matsumoto et al. Case Rep Gastroenterol. .

Abstract

Median arcuate ligament syndrome (MALS) is caused by constriction of the celiac artery (CA) by the median arcuate ligament of the diaphragm. Ligament release improves perfusion of the CA, resulting in resolution of abdominal symptoms. A 51-year-old female had postprandial abdominal pain for 10 years and underwent computed tomography (CT) scan showing severe stenosis of the CA with pancreatoduodenal arcade aneurysm formation. MALS was diagnosed, and open median arcuate ligament incision was performed to decompress the CA. Intraoperative ultrasonography showed bidirectional turbulent flow in the common hepatic artery (CHA). The median arcuate ligament was uneventfully incised, and compression of the CA released. The perfusion in the CHA was changed to an antegrade direction, and the flow increased. Seven days after the laparotomy, the patient was discharged uneventfully. Follow-up CT scan 20 days after operation showed a diminished pancreatoduodenal arcade aneurysm and inferior pancreatoduodenal artery. Epigastric pain and postprandial distress symptoms were improved. In conclusion, perfusion of the CHA became normalized after median arcuate ligament release. Surgical intervention for MALS not only improved blood flow in the tributaries but also diminished the pancreatoduodenal arcade aneurysm.

Keywords: Common hepatic artery; Decompression; Median arcuate ligament syndrome; Pancreatoduodenal arcade aneurysm; Therapeutic outcome; Ultrasound.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
a Preoperative 3D-CT scan. The median arcuate ligament compresses the CA (13 mm in length, 0.8 mm in diameter) (white arrow). There is an inferior pancreatoduodenal arcade aneurysm (118.9 mm3) (blue arrow). b Postoperative 3D-CT scan showed decompression of the CA up to 2.4 mm in diameter. The inferior pancreatoduodenal arcade aneurysm is diminished to 82.3 mm3 (blue arrow). 3D-CT, three-dimensional computed tomography.
Fig. 2
Fig. 2
Surgical procedure for MALS. a The median arcuate ligament (white arrow heads) is incised anterior to the abdominal aorta after controlling the CHA (white arrow), SA (yellow arrow), and LGA (blue arrow). b After the incision, the CA becomes enlarged and pulsatile (green arrow). SA, splenic artery; LGA, left gastric artery.
Fig. 3
Fig. 3
Schema of visceral perfusion. a Before median arcuate ligament incision, the CHA perfusion is turbulent, with a mean rate of 3 mL/min in a retrograde direction. Flow in both the SA (66 mL/min) and LGA (17 mL/min) is antegrade. b After incision, the flow in the CHA changed to an antegrade direction at a rate of 38 mL/min. Antegrade flow is observed in the SA (48 mL/min), LGA (15 mL/min), and CA (40 mL/min). SA, splenic artery; LGA, left gastric artery.
See this image and copyright information in PMC

References

    1. Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, et al. European guidelines on chronic mesenteric ischaemia: Joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J. 2020 May;8((4)):371–95.
    1. Miyamotto M, Kanegusuku CN, Okabe CM, Claus CMP, Ramos FZ, Rothert Á, et al. Laparoscopic treatment of celiac axis compression by the median arcuate ligament and endovascular repair of a pancreaticoduodenal artery aneurysm: case report. J Vasc Bras. 2018 Jul–Sep;17((3)):252–6. - PMC - PubMed
    1. Moak JP, Ramwell C, Fabian R, Hanumanthaiah S, Darbari A, Kane TD. Median arcuate ligament syndrome with orthostatic intolerance: intermediate-term outcomes following surgical intervention. J Pediatr. 2021 Apr;231:141–7. - PubMed
    1. Roayaie S, Jossart G, Gitlitz D, Lamparello P, Hollier L, Gagner M. Laparoscopic release of celiac artery compression syndrome facilitated by laparoscopic ultrasound scanning to confirm restoration of flow. J Vasc Surg. 2000 Oct;32((4)):814–7. - PubMed
    1. Kakuta E, Yamashita N, Katsube T, Kushiyama Y, Suetsugu H, Furuta K, et al. Abdominal symptom-related QOL in individuals visiting an outpatient clinic and those attending an annual health check. Intern Med. 2011;50((15)):1517–22. - PubMed

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