Chronic Mesenteric Ischemia from Diaphragmatic Compression of the Celiac and Superior Mesenteric Arteries

Median arcuate ligament syndrome (MALS) is caused by extrinsic compression of the celiac axis leading to postprandial epigastric abdominal pain, weight loss, and vomiting. The condition is most often identified in young women, and it is a controversial, unusual cause of chronic mesenteric ischemia. Rarely, the median arcuate ligament can compress the superior mesenteric artery (SMA) in addition to the celiac artery. We present a case of MALS in a young female patient with chronic abdominal pain resulting from external compression of not only the celiac artery but also the SMA. This patient was treated with release of the median arcuate ligament via an open retroperitoneal approach in addition to limited endarterectomy and patch angioplasty of the SMA. Preoperative and postoperative 3-dimensional computed tomographic angiographic images depict the lesions and their resolution after surgery. Few other cases of MALS caused by compression of both the celiac artery and SMA have ever been described in the literature. Although rare, it is important to keep the diagnosis of MALS in mind when encountering certain patients with chronic mesenteric ischemia of unclear etiology. Updated diagnostic work-up and treatment options for this condition are described.