Median arcuate ligament syndrome

Case contributed by Dr Piyush P Siwach

Presentation

Reports calcification from x-ray, ? abdominal aortic aneurysm.

Patient Data

Age: 65 years
Gender: Male

Contrast enhanced arterial phase CT scan of upper abdomen demonstrate

  1. Relatively high origin of the celiac artery which is narrowed just distal to the ostium by the median arcuate ligament of diaphragm. 
  2. The superior and inferior pancreaticoduodenal arteries are quite prominent and tortuous suggesting collateral circulation between SMA and celiac axis circulation, and show heavy atherosclerotic disease, which is disproportionately severe when compared with aorta and its other branches.
  3. A saccular aneurysm with calcified walls measuring approximately 20 x 20mm arising from the inferior pancreaticoduodenal artery.
  4. Heavy atherosclerotic calcifications in the splenic artery and in pancreaticoduodenal arteries. No splenic artery aneurysm is seen. secondary to celiac artery narrowing. , measuring 20 x 20 mm.
  5. Incidentally, a Bosniak class 2 lesion, bordering class 3. 

Case Discussion

Anatomically, the appearance in this study is consistent with celiac artery compression by medial arcuate ligament due to its high origin. However, the abnormality was detected incidentally, while investigating calcifications observed on xray. Patient did not have any specific symptoms of "upper abdominal angina", apparently due to excellent collaterals between superior mesenteric and coelaic axis circulation via pancreaticoduodenal collaterals. However, this high volume collateral flow has resulted results in atherosclerotic disease of the pancreaticuduodenal arteries, which is disproportionate to the atheroslerotic disease in aorta and its other branches, and an aneurysm of the inferior pancreaticoduodenal artery, which is otherwise an uncommon location of such aneurysms.

The symptoms in this patient did not warrant a surgical treatment, but the patient was referred to a vascular surgeon regarding his aneurysm.

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Case information

rID: 53548
Published: 23rd May 2017
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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