Median arcuate ligament syndrome with post stenotic pancreaticoduodenal aneurysm: case report

  • Jurica Zedelj Department of Surgery, University Hospital Center Zagreb, Zagreb, Croatia
  • Vedrana Biosic County Hospital Čakovec
  • Hrvoje Silovski Department of Surgery, University Hospital Center Zagreb, Zagreb, Croatia
  • Igor Petrovic Department of Surgery, University Hospital Center Zagreb, Zagreb, Croatia
  • Tomislav Mestrovic Department of Surgery, University Hospital Center Zagreb, Zagreb, Croatia
  • Drazen Perkov Clinical Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Croatia
Keywords: median arcuate ligament, chronic mesenterial ischemia, aneurysm, celiac artery compression syndrome

Abstract

Background: Median arcuate ligament syndrome (celiac artery compression syndrome, Dunbar syndrome) is an infrequent form of chronic mesenterial ischemia. The culprit for a sub optimal celiac blood flow is a lowpositioned median arcuate ligament which is an arch of fibrous tissue connecting the diaphragmatic crura. Symptomatic patients complain of postprandial pain situated in the epigastrium. Still, most of the individuals proven to have some form of celiac artery compressions report no complaints at all. The gold standard for diagnosis is a CT angiography and treatment is surgical. The median arcuate ligament is transacted with or without additional endovascular treatment.

Case study: We present the case of a 50-year-old male patient with a radiologically confirmed diagnosis of median arcuate ligament syndrome treated surgically at our institution. An open approach was used since the patient had a previous median laparotomy scar. Due to a post stenotic pancreaticoduodenal aneurysm coil embolization was additionally performed. On follow up the patient had no further complaints.

Conclusion: Patients with chronic postprandial pain require a systematic approach. In the differential diagnosis of abdominal angina, although uncommon, median arcuate ligament syndrome is to be remembered. The diagnosis is rather straightforward once clinical suspicion is established and treatment-wise minimally invasive surgery is performed whenever possible.

Downloads

Download data is not yet available.

References

Skandalakis LJ, Skandalakis JE. Median Arcuate Ligament. In: Surgical Anatomy and Technique: A Pocket Manual; 4th Ed.; 2014:2584-2603.

Dunbar D, Molnar W, Marable SA, BEMAN FF. Compression of the celiac trunk and abdominal angina* preliminary report of 15 cases. American Journal of Roentgenology. 1965;95(3):731-744.

Fong JKK, Poh ACC, Tan AGS, Taneja R. Imaging findings and clinical features of abdominal vascular compression syndromes. American Journal of Roentgenology. 2014;203(1):29-36. doi:10.2214/ AJR.13.11598

You JS, Cooper M, Nishida S, Matsuda E, Murariu D. Treatment of Median Arcuate Ligament Syndrome Via Traditional and Robotic Techniques. Hawaii J Med Public Health. 2013; 72(8): 279–281.

Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: Evaluation with CT angiography. Radiographics. 2005;25(5):1177-1182. doi:10.1148/rg.255055001

Kuruvilla A, Murtaza G, Cheema A, Arshad HMS. Median Arcuate Ligament Syndrome: It Is Not Always Gastritis. Journal of Investigative Medicine High Impact Case Reports. 2017;5(3). doi:10.1177/2324709617728750

Lindner HH, Kemprud E. A Clinicoanatomical Study of the Arcuate Ligament of the Diaphragm. Arch Surg. 1971 Nov;103(5):600-5.

Rodbard S, Ikeda K, Montes M. An analysis of mechanisms of post stenotic dilatation. Angiology. 1967 Jun;18(6):349-67.

Skeik N, Cooper LT, Duncan AA, Jabr FI. Median arcuate ligament syndrome: A nonvascular, vascular diagnosis.

Vascular and Endovascular Surgery. 2011;45(5):433-437. doi:10.1177/1538574411406453

Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. Celiac Axis Stenosis: Incidence and Etiologies in Asymptomatic Individuals. Journal of Vascular Surgery.; 1988.

Tulloch AW, Jimenez JC, Lawrence PF, et al. Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome. Journal of Vascular Surgery. 2010;52(5):1283-1289. doi:10.1016/j.jvs.2010.05.083.

Published
2021-09-28
How to Cite
1.
Zedelj J, Biosic V, Silovski H, Petrovic I, Mestrovic T, Perkov D. Median arcuate ligament syndrome with post stenotic pancreaticoduodenal aneurysm: case report. Acta Chir. Croat. [Internet]. 2021Sep.28 [cited 2021Oct.17];18(1):29-1. Available from: https://acc.hkd.com.hr/index.php/ACC/article/view/128
Section
Case Reports