Problems with the Median Arcuate Ligament Should Be Recognized before Surgery; Its Importance in Pancreaticoduodenectomy

Abstract

Background: Celiac artery stenosis (CAS) is a not a rare finding in the general population. The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus and, while it normally passes cranial to the origin of the celiac truncus, a low-lying ligament may lead to compression of the celiac artery and is the one of the major causes of CAS. Case Report: In this paper, we present a patient with a mass in the gastric bulbus who was diagnosed with celiac artery stenosis during the pancreaticoduodenectomy (PD). MAL was the cause of the celiac artery stenosis, determined based on the findings of preoperative computed tomography (CT). Conclusion: Although CAS is usually asymptomatic due to the collateral blood supply, it may be associated with potentially disastrous results due to ischemia of the upper abdominal organs as a result of disruption of the collateral pathways. It is especially important to recognize the presence of CAS and its etiology before interventional procedures. With the increasing use of multidetector computed tomography (MDCT), it becomes essential for radiologists to be aware of this entity and the cross-sectional findings.

Keywords

• Celiac artery, median arcuate ligament, multidetector computed tomography, pancreaticoduodenectomy

Kaynakça

1. 1. Bron KM, Redman HC. Splanchnic artery stenosis and occlusion. Radiology 1969;92:323-8. [CrossRef]
2. 2. Kwon JW, Chung JW, Song SY, Lim HG, Myung JS, Choi YH, et al. Transcatheter arterial chemoembolization for hepatocellular carcinomas in patients with celiac axis occlusion. J Vasc Interv Radiol 2002;13:689-94. [CrossRef]
3. 3. Gloviczki P, Duncan AA. Treatment of celiac artery compression syndrome: does it really exist? Perspect Vasc Surg Endovasc Ther 2007;19:259-63. [CrossRef]
4. 4. Bull DA, Hunter GC, Crabtree TG, Bernhard VM, Putnam CW. Hepatic ischemia, caused by celiac axis compression, complicating pancreaticoduodenectomy. Ann Surg 1993; 217:244-7. [CrossRef]
5. 5. Levin D C, Baltaxe H A. High incidence of celiac axis narrowing in asymptomatic individuals. Am J Roentgenol Radium Ther Nucl Med 1972;116:426-9. [CrossRef]
6. 6. Harjola PT. A rare obstruction of the coeliac artery: report of a case. Ann Chir Gynaecol Fenn 1963;52:547-50.
7. 7. Park CM, Chung JW, Kim HB, Shin SJ, Park JH. Celiac axis stenosis: incidence and etiologies in asymptomatic individuals. Korean J Radiol 2001;2:8-13. [CrossRef]
8. 8. Ilica AT, Kocaoglu M, Bilici A, Ors F, Bukte Y, Senol A, et al. Median arcuate ligament syndrome: multidetector computed tomography findings. J Comput Assist Tomogr 2007;31:728-31.

9. 9. Berney T, Pretre R, Chassot G, Morel P. The role of revascularization in celiac occlusion and pancreatoduodenectomy. Am J Surg 1998;176:352-6. [CrossRef]
10. 10. Kurosaki I, Hatakeyama K, Nihei KE, Oyamatsu M. Celiac axis stenosis in pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg 2004;11:119-24. [CrossRef]
11. 11. Kohler TR, Debas H, Crames M, Strandness DE Jr. Pancreaticoduodenectomy and the celiac artery compression sndrome. Ann Vasc Surg 1990;4:77-80. [CrossRef]
12. 12. Farma JM, Hoffman JP. Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy. Am J Surg 2007;193:341-4. [CrossRef]
13. 13. Sugae T, Fujii T, Kodera Y, Kanzaki A, Yamamura K, Yamada S, et al. Classification of the celiac axis stenosis owing to median arcuate ligament compression, based on severity of the stenosis with subsequent proposals for management during pancreaticoduodenectomy. Surgery 2012;151:543-9. [CrossRef]
14. 14. Raman SP, Horton KM, Cameron JL, Fishman EK. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol 2013;201:2-13. [CrossRef]
15. 15. Song SY, Chung JW, Kwon JW, Joh JH, Shin SJ, Kim HB, et al. Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation. Radiographics 2002;22:881-93. [CrossRef]
16. 16. Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics 2005;25:1177-82.[CrossRef]