Transthoracic Median Arcuate Ligament Release and Mesenteric Revascularization

Surgical revascularization for chronic or acute mesenteric ischemia is often technically challenging. In many instances, because of the presence of hostile abdominal conditions or the lack of adequate intra-abdominal arterial inflow sources, alternative surgical approaches that avoid the abdomen and use a more proximal source of arterial inflow are necessary. In these situations, a bypass from the descending or ascending thoracic aorta to the mesenteric vessels may be the only viable option. However, the standard thoracoabdominal approach for mesenteric revascularization carries an extensive surgical insult, and in some situations, this approach does not obviate hostile abdominal pathology. We here describe a transthoracic surgical technique that allows antegrade celiac and mesenteric revascularization without a thoracoabdominal incision. This approach facilitates the easy transection of the median arcuate ligament of the diaphragm and, when needed, resection of the celiac autonomic ganglia. The transthoracic mesenteric revascularization is less invasive than a thoracoabdominal approach, whereas allowing a similar antegrade, short bypass to the mesenteric vessels from the descending thoracic aorta equal to that done through a thoracoabdominal exposure. This procedure provides a superb approach for the treatment of median arcuate ligament syndrome, and an excellent alternative for mesenteric revascularization when avoidance of the abdomen is advisable.