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May 2016

Median Arcuate Ligament Syndrome—Review of This Rare Disease

Author Affiliations
  • 1Medical student, Jefferson Medical College, Philadelphia, Pennsylvania
  • 2now with Department of Surgery, University of California, San Francisco (UCSF), Fresno
  • 3Division of Vascular and Endovascular Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
  • 4Division of Vascular Surgery, University of South Florida, Tampa
  • 5Division of Vascular and Endovascular Surgery, Advanced Surgical Associates of New Jersey, Pennington
JAMA Surg. 2016;151(5):471-477. doi:10.1001/jamasurg.2016.0002

Importance  Median arcuate ligament (MAL) syndrome is a rare disease resulting from compression of the celiac axis by fibrous attachments of the diaphragmatic crura, the median arcuate ligament. Diagnostic workup and therapeutic intervention can be challenging.

Objective  To review the literature to define an algorithm for accurate diagnosis and successful treatment for patients with MAL syndrome.

Evidence Review  A search of PubMed (1995-September 28, 2015) was conducted, using the key terms median arcuate ligament syndrome and celiac artery compression syndrome.

Findings  Typically a diagnosis of exclusion, MAL syndrome involves a vague constellation of symptoms including epigastric pain, postprandial pain, nausea, vomiting, and weight loss. Extrinsic compression of the vasculature and surrounding neural ganglion has been implicated as the cause of these symptoms. Multiple imaging techniques can be used to demonstrate celiac artery compression by the MAL including mesenteric duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, gastric tonometry, and mesenteric arteriography. Surgical intervention involves open, laparoscopic, or robotic ligament release; celiac ganglionectomy; and celiac artery revascularization. There remains a limited role for angioplasty because this intervention does not address the underlying extrinsic compression resulting in symptoms, although angioplasty with stenting may be used in recalcitrant cases.

Conclusions and Relevance  Median arcuate ligament syndrome is rare, and as a diagnosis of exclusion, diagnosis and treatment paradigms can be unclear. Based on previously published studies, symptom relief can be achieved with a variety of interventions including celiac ganglionectomy as well as open, laparoscopic, or robotic intervention.

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