Given the findings of asymptomatic celiac artery compression and the multitude of causes for abdominal pain, it is crucial that patients are evaluated for all possible etiologies of abdominal pain prior to being diagnosed with celiac artery compression. There has currently been very little published with specific protocols for diagnosis. Mak et al. reported the use of a specific diagnostic protocol. Complete medical evaluation should include blood work (CBC, chemistry panel, liver function tests, amylase, lipase, erythrocyte sedimentation rate, C-reactive protein, prealbumin, thyroid function tests), upper GI, small bowel follow-through, abdominal ultrasound, upper endoscopy with biopsy, and evaluation for inflammatory bowel disease and celiac disease. Patients are then screened with mesenteric duplex. Positive findings consist of peak systolic velocities (PSV) in the celiac artery greater than 200 cm/s and an end diastolic velocity (EDV) greater than 55 cm/s. Further demonstration of a decrease in PSV with deep inspiration is suggestive of celiac artery compression. El-Hayek et al. utilized similar diagnostic criteria of PSV >200 cm/s in both inspiratory and expiratory phases [8]. Sultan et al. used these criteria as well as retrograde flow within the hepatic artery (100 % predictive of severe celiac stenosis or occlusion) [1]. Patients then undergo CT angiogram to evaluate the conformation of the celiac artery in both inspiratory and expiratory phases [3].

Once the diagnosis is confirmed, it is crucial that patients are evaluated for proper patient selection for surgical intervention. Patient characteristics reported to be predictive of successful outcomes following surgery include post-prandial pain, age from 40 to 60 years, and weight loss of 10 kg or greater. Factors predictive of persistence of symptoms following surgery include atypical pain, periods of remission, age over 60 years, history of psychiatric or alcohol abuse, and weight loss of less than 10 kg [3, 6, 8, 10, 11].

Additionally, Mak et al. reported incorporating psychiatric and chronic pain service in the pre-operative and post-operative evaluations given the correlation between chronic physical pain and psychological pain. Pre-operatively, all patients are evaluated by a multi-disciplinary team consisting of general and vascular surgery, psychiatry, and pain service. This team then discusses each patient, and surgery is not considered until the patient has been unanimously cleared by the entire team [3].

Mensink described the “gastric exercise test” to detect gastrointestinal ischemia. Before, during, and after 10 min of exercise, gastric tonometry was performed measuring gastric and arterial PCO₂. Positive results were defined as gastric-arterial PCO₂ gradient >0.8 kPa after exercise, increase in gastric PCO₂ from baseline to peak exercise, and an arterial lactate level <8 mmol/L. Following surgical release of the celiac artery compression, repeat tonometry was performed at 3 and 6 months. All patients who were symptom-free post-operatively had normalized tonometry results while only 25 % of patients with persistent symptoms showed normalized results. While this is not a single test that can predict success, it is an additional test to add to one’s armamentarium during the evaluation for surgical candidacy [5, 8, 12].

Published techniques for the surgical release of celiac artery compression consist of open, laparoscopic, and robotic procedures (all of which have been shown to be safe and effective). The general principles and goals of the procedures are similar – division of the median arcuate ligament including overlying lymphatics and soft tissue to release the celiac artery with or without division of the celiac nerve plexus. Some use intra-operative duplex to verify adequate release while others determine adequate release by conformational change of the celiac artery. While there is debate regarding performance of celiac artery revascularization procedures concomitantly with the release or at a later date if symptoms recur, there is a general consensus not to perform endovascular stenting of the celiac artery pre-operatively as these stents generally fail due to external compression from the median arcuate ligament [1, 4, 5, 13]. One novel approach was described by van Petersen in which retroperitoneal endoscopic lysis of the median arcuate ligament was performed with similar safety and success rates [14].

The data that currently exists regarding the efficacy of surgery is quite limited with relatively short follow-up. The literature mostly consists of retrospective reviews consisting of relatively small case numbers [1–5, 7, 8, 11, 13–20]. Overall, reviews have found generally good outcomes following surgical treatment including release of the ligament (laparoscopic and open), neurolysis, and celiac artery revascularization with the majority of studies showing improved post-operative abdominal pain. Average success rate of being symptom-free following surgical intervention is reported to be 70–80 % [15, 16]. Table 22.2 summarizes the findings of retrospective reviews evaluating the efficacy of surgical treatment for celiac artery compression [1–5, 7, 8, 11, 13, 14, 17–20].