CELIAC ARTERY COMPRESSION SYNDROMES
Section snippets
HISTORY
Harjola's report 15 of the first operative case in which the celiac axis was released from compression by division of a “fibrotic celiac ganglion” was followed by a number of similar reports in the mid to late 1960s. In a 1965 review of their experience with several varieties of chronic mesenteric ischemia, Dunbar and his colleagues 2 at Ohio State University reported on 15 patients in whom division of the median arcuate ligament (not the celiac ganglion), releasing the CA from extrinsic
LATER SERIES
In 1974, Evans, 10 updating the Ohio State experience, largely fulfilled Szilagyi's prediction when he reported disappointing late follow-up on what was at the time the largest number of patients undergoing operation for the syndrome at one institution. After 3 to 11 years, 50% of 44 patients had persistent symptoms, which compared unfavorably with a smaller group with the same diagnosis treated nonsurgically: 9 of 12 of these were pain free and had later been given additional diagnoses of
CLINICAL HISTORY
Celiac compression syndromes affect females more often than males, in a ratio of nearly 4 to 1. Age at presentation is typically between 20 and 50, but extremes of age from 13 to 78 have been reported. An asthenic body habitus has been described by a minority of authors. The cardinal symptom is chronic abdominal pain, usually gradual in onset and beginning months or even years prior to presentation. Few authors have noted in their patients a reliable pattern of pain that is recognizable to
PHYSICAL EXAMINATION
Several authors have observed that a slender physique with a narrow subcostal angle25 is commonly present, but this is certainly not essential to the diagnosis. The hallmark of the physical examination is an epigastric bruit, which in most cases, but not all, becomes louder during expiration. Unfortunately, like the cardinal symptom of pain, this too is a nonspecific finding because examinations of normal, symptom-free individuals detect epigastric bruits in 6.5% to 30%.17 Whether variation
DIAGNOSTIC TESTS
CA compression syndrome is, in practice, very much a “diagnosis of exclusion.” Accordingly, the entire lengthy differential diagnosis of chronic abdominal pain has usually been considered and thoroughly investigated before this diagnosis is entertained. This is entirely appropriate. The aforementioned incidence of CA compression in normal, asymptomatic individuals, indicated both by epigastric bruit and by arteriographic demonstration of CA impingement, is high. It only makes sense (and has
CASE SELECTION
The most challenging aspect of CA compression syndrome is correctly identifying the patient who will benefit from surgical correction. The cardinal symptom (pain), the critical physical finding (bruit), and the “definitive” diagnostic finding (CA compression) are each to some degree nonspecific, so the “chance concurrence…of these phenomena from time to time, without…cause and effect relationship” might be expected. Of course, the same can be said for the concurrence of abdominal pain and
SURGICAL THERAPY
Clearly, the most difficult step in the surgical treatment of CA compression syndrome is the decision whether to operate. A frank preoperative discussion with the patient that acknowledges the complexity of this decision is always worthwhile. The typical young, otherwise healthy patient with debilitating pain is usually more than willing to accept a possible lack of efficacy in exchange for the greater possibility of pain relief, especially because a laparotomy offers additional diagnostic
ANATOMIC BASIS FOR CA COMPRESSION
In development, the CA originates in the cervical region and descends caudally. In 85% of cadaver dissections its anterior origin from the aorta occurs between the upper third of the eleventh thoracic vertebra and the upper third of the twelfth.4 In general, a more proximal CA origin occurs in females than in males, which is consistent with the female predominance of the CA compression syndrome. A wide variation also exists in the length (8 to 40 mm) and caliber (7 to 20 mm) of the CA.28
A 1917
SUMMARY
Compression of the visceral arteries can produce true mesenteric ischemia, but the syndrome is rare. The syndrome is caused by unfavorable anatomic relationships at the aortic hiatus among the CA, the SMA, and overlying structures, particularly the diaphragmatic crura. These anatomic relationships, in contrast to the syndrome they sometimes produce, are relatively common, which makes the detection of CA compression only a prerequisite to the diagnosis of the clinical entity. The diagnosis of CA
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2020, Journal of Vascular SurgeryCitation Excerpt :Chronic compression by the MAL can lead to hyperplastic intimal changes of the celiac artery. Histologic studies have demonstrated an abundance of smooth muscle proliferation, abnormal elastic fibers, and disorganized medial and adventitial layers that may advance to cause complete arterial occlusion in patients with MALS.6 Downstream of the stenosis, poststenotic dilation and celiac artery aneurysms can complicate MALS further.
Factors Associated with Symptomology of Celiac Artery Compression and Outcomes following Median Arcuate Ligament Release
2020, Annals of Vascular Surgery
Address reprint requests to Fritz R. Bech, MD Section of Vascular Surgery Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756