Fig. 5.1
Angiography for suspected chronic mesenteric ischemia demonstrates (a) proximal celiac stenosis and total SMA occlusion, which was treated with (b) balloon-expandable stent placement to both vessels with clinical improvement in symptoms.
Complications
Distal embolization. Small emboli may be clinically inconsequential. Larger emboli may precipitate AMI, and should be treated with aspiration embolectomy or thrombolysis.
Vessel dissection. Treat with self-expanding stent placement.
Access site complications. Hematoma and pseudoaneurysm.
Follow-Up
Clopidogrel 75 mg daily for 1 month followed by aspirin 325 mg daily for 1 month. Mesenteric duplex ultrasound should be obtained postoperatively to establish a baseline again at 6 months, and 12 months thereafter, and ultimately annually.
Median Arcuate Ligament Syndrome (MALS)
Clinical Presentation
Most patients are thin young women who present with symptoms of CMI; alternatively, patients may have exercise-induced abdominal pain.
Pathophysiology
The median arcuate ligament is created by crossing fibers from the right and left diaphragmatic crura. An abnormally low diaphragm or superior origin of the celiac artery leads to compression of the latter and rarely the SMA as well. This is exacerbated during inspiration and improves with expiration, when the aorta undergoes physiologic anteroinferior displacement. Celiac compression causes pain via foregut ischemia or a steal phenomenon, wherein blood is diverted from the SMA circulation, leading to midgut hypoperfusion. Recurrent celiac compression by the MAL or by the associated celiac ganglion may lead to pathologic changes in its histologic structure.
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