Case Reference No. CC-997-05 The patient is a 74-year-old man complaining of postprandial pain and a 14-pound weight loss over a 4­6-week period who was referred to our institution for visceral angioplasty. Prior work-up included normal upper and lower endoscopy, abdominal ultrasound, and abdominal CT. An outside arteriogram demonstrated occlusion of the celiac artery origin. The patient was referred to us by a vascular surgeon for celiac artery recanalization and possible stent placement. Lateral abdominal arteriography performed during inspiration and expiration confirmed severe narrowing of the celiac artery that changed in severity during respiration (Figs. 1, 2). This was attributed to extrinsic compression by the median arcuate ligament. An AP aortogram demonstrated a lack of significant interarterial anastomoses between the celiac and superior mesenteric arteries (Fig. 3). We elected not to treat this patient, as we believed that it was unlikely that this patient's symptoms were referable to this extrinsic compression. Many authors question the existence of symptomatic mesenteric ischemia caused by median arcuate compression. However, there are numerous reports in the literature describing patients with similar symptoms who have undergone division of the median arcuate ligament with improvement in their symptoms. There is even a case report describing a pair of monozygotic twins with gastrointestinal complaints that resolved after each had division of their median arcuate ligament.		Fig. 1. Lateral aortogram obtained during expiration demonstrates high-grade stenosis of the celiac artery (arrow) with a widely patent superior mesenteric artery. Fig. 2. Lateral aortogram obtained during inspiration demonstrates marked improvement in the celiac artery stenosis (arrow). Fig. 3. AP aortogram demonstrates a lack of significant interarterial communications between the celiac and superior mesenteric arteries.
Questions 1) Does median arcuate ligament syndrome cause symptoms? 2) Has anyone treated median arcuate ligament syndrome successfully with angioplasty or stent placement? 3) Does the absence of enlarged pancreaticoduodenal SMA to celiac artery arcades prove that these stenoses are not significant? 4) Can a solitary celiac artery lesion account for these symptoms?