Median arcuate ligament syndrom (MALS), also known as celiac axis compression syndrome (CACS) and its eponym Dunbar Syndrome, is manifest as epigastric abdominal pain and a compendium of symptoms, arising from chronic compression and inflammation resulting from compression of the celiac plexus between the median arcuate ligament and the celiac axis.
The diaphragm muscle descends from the neck during development (the phrenic nerve originates from C3-C5 nerve roots), and in perhaps up to 25 percent of individuals, drapes across the origin of the celiac axis, and sometimes anchors further down impinging on the SMA or renal artery origins.
While a significant number of patients have this coverage of the celiac axis origin, not everyone has pain. Some whose celiac axis is compressed develop post-stenotic dilatation. For some of these, there is damage to the celiac axis resulting in intimal injury, dissections, thromboses, webs. Turbulent flow causing post-stenotic dilatation in the celiac axis can proceed to aneurysm formation. Downstream in the splenic and hepatic artery and its branches, turbulent flow can engender tortuosity (lengthening) and aneurysms (widening). This disease subset of celiac axis compression should be termed aMALS (arterial median arcuate ligament syndrome).
Both arterial and neurogenic manifestations of celiac axis compression are under the same ICD code of I77.4, referring to both celiac axis compression syndrome and median arcuate ligament syndrome. While I would never suggest more ICD codes, there should be a differentiation similar to the other compression syndrome, thoracic outlet syndrome (TOS). The pain-based syndrome, which is more common, should be termed neurogenic MALS, or nMALS, and the arterial disease secondary to celiac axis compression should be termed arterial MALS or aMALS. The treatment of nMALS is surgical ablation of the celiac plexus along with median arcuate ligament release, done via open, laparoscopic, and robotic techniques. The treatment of aMALS is the treatment of the arterial complications of celiac axis compression and should involve median arcuate release and treatment of the arterial pathology with either open or endovascular techniques.
Case Presentation
The patient is a middle-aged man with several months of right sided abdominal pain, mostly in the right midaxillary line at the costal margin, right upper quadrant abdominal pain, and right sub-scapular pain. He did not have gallstones, and had no gastrointestinal complaints. He is hypertensive and was on a single agent which he took in the mornings. His pain began during the day and crescendoed in the evening. His prior visits to the emergency room had revealed a hepatic artery aneurysm and celiac axis aneurysm. In the ED, his examination was significant for pain and mild tenderness in the right upper quadrant of his abdomen. He underwent a CT scan.
The CTA showed compression of the first centimeter of the celiac axis by the median arcuate ligament of the diaphragm and mild post-stenotic dilatation to 14mm. At the terminus of the common hepatic artery, where the hepatic bifurcated was a 2.4cm aneurysm with mural thrombus. With blood pressure control, his pain remitted.
The trainees and I had a lively discussion as to indications for repair and whether this constituted a symptomatic aneurysm. As I have stated in past posts, all pain has a nerve and a mechanism for pain. Abdominal pain and its points of referral are well known going back to the 19th century and encapsulated in Cope’s Early Diagnosis of the Acute Abdomen, whose most recent steward, Dr. William Silen just passed this September. Processes involving the gallbladder and nearby hepatic artery refer to the right upper quadrant abdomen, right chest, right shoulder and scapula which was where the patient’s pain was. And it improved with controlling his hypertension. There was no question to me the aneurysm was symptomatic, likely from strain on the aneurysm.
The question then devolves to whether this is to be done endovascularly or open. While it seems straightforward for me, I have realized at large meetings there will always be some endovascularist proposing something. For me, to exclude pressure from the aneurysm and avoid rupture, the aneurysm had to be isolated from the blood flow and pressure. Ideally, this would be done with tiny covered stents.
There are no 7mm x 4mm stents bifurcation stents.
Embolization of the hepatic aneurysm, which is done for the splenic, offers hazard of hepatic ischemia. Despite what is written in the textbooks about the portal venous system providing most of the perfusion of the liver, you have to remember there is only portal flow when there is food. Acutely losing one of the hepatics, even clamping it for a time, reverberates as a spike in the LFTs, along with attendant systemic inflammatory response. While the liver, like spleen, can recover and regrow, you mess with it at your great peril. Based on the CTA, closing the hepatic artery with coils and plugs will likely be tolerated as hepatic flow would continue via the gastroduodenal artery which is not small, but there is no guarantee that the aneurysm wouldn’t be pressurized yet by the prominent GDA (if you disagree please feel free to comment).
He was prepared for surgery with echocardiography (normal) and lab testing (normal LFT’s, CBC, BMP, INR), and taken to the OR. A chevron incision was made to broadly expose the area. The median arcuate ligament was exposed and released -there was dense tissues proximal to the dilated celiac axis. The aneurysm was dissected out and the small branches were carefully dissected out and controlled. It is easy to injure the branch hepatic arteries which can constrict on dissection.
A suitable length of saphenous vein was harvested and prepared. The three vessels diagrammed above did not present themselves suitable for a single Carrel patch so I sewed end to end to a patch incorporating the right hepatic and gastroduodenal arteries, and performed a sequential side to end anastomosis to the left gastric artery.
The patient recovered well and was discharged home on POD#5, and in followup had no further symptoms.
Discussion:
The differentiation of arterial and neurogenic manifestations of MALS is an important refinement of our understanding of this disease, which I believe to be a byproduct of our bipedal lifestyle. The lordotic curvature of the spine, necessary to balance our upper torso on a vertical spine, pushes the spine forward and applies tension to the median arcuate ligament, along with other structures such as the duodenum and left renal vein in superior mesenteric artery syndrome and nutcracker syndrome, and the left iliac vein in May-Thurner Syndrome.
This compression is not only enough to narrow the celiac, but injure the artery by crushing. Stenting here does not do well because of the external compression and even after release, the artery may be damaged and require repair.
The chevron exposure heals well and is well tolerated and offers perfect exposure. While I was doing it, it occurred to me that a laparoscopic bypass is technically possible, and may be preferred to the long incision. Recent multi-institution study of MALS treatment would suggest laparoscopic approach offers a lower complication rate compared to open surgery (ref 2.)
The critical thing is having more surgeons recognize the compression that occurs in the abdomen and manifests in disparate and unconventional ways. The key is tying pain to a lesion, a mechanism, a nerve, just the way Cope’s does.
References
- Weber JM, Boules M, Fong K, Abraham B, Bena J, El-Hayek K, Kroh M, Park WM. Median Arcuate Ligament Syndrome Is Not a Vascular Disease. Ann Vasc Surg. 2016 Jan;30:22-7. doi: 10.1016/j.avsg.2015.07.013. Epub 2015 Sep 10. PMID: 26365109.
- DeCarlo C, Woo K, van Petersen AS, Geelkerken R, Chen AJ, Yeh SL, Kim GY, Henke PK, Tracci MC, Schneck MB, Grotemeyer D, Meyer B, DeMartino RR, Wilkins PB, Iranmanesh S, Rastogi V, Aulivola B, Korepta LM, Shutze WP, Jett KG, Sorber R, Abularrage CJ, Long GW, Bove PG, Davies MG, Miserlis D, Shih M, Yi J, Gupta R, Loa J, Robinson DA, Gombert A, Doukas P, de Caridi G, Benedetto F, Wittgen CM, Smeds MR, Sumpio BE, Harris S, Szeberin Z, Pomozi E, Stilo F, Montelione N, Mouawad NJ, Lawrence P, Dua A. Factors Associated With Successful Median Arcuate Ligament Release in an International, Multi-Institutional Cohort. J Vasc Surg. 2022 Oct 25:S0741-5214(22)02443-0. doi: 10.1016/j.jvs.2022.10.022. Epub ahead of print. PMID: 36306935.
A Surgeon's Notes 