Work

Simultaneous Celiac and Pancreaticoduodenal Artery Aneurysms in Median Arcuate Ligament Syndrome: Successful Long-Term Management via Staged Hybrid Treatment

Year: 2026

Type: article

Abstract: INTRODUCTION: Median arcuate ligament syndrome (MALS) is characterized by chronic mesenteric ischemia resulting from external compression of the celiac artery (CA). While rare, this compression can alter local hemodynamics, potentially leading to the formation of visceral artery aneurysms. Although pancreaticoduodenal artery (PDA) aneurysms are a known collateral complication, the concurrent presentation of a poststenotic CA aneurysm and a collateral PDA aneurysm is exceedingly rare. We report the long-term outcomes of a patient with MALS complicated by simultaneous aneurysms of both the CA and the PDA. CASE PRESENTATION: A 59-year-old woman was admitted with sudden, severe abdominal and back pain. Imaging revealed severe hook-shaped stenosis of the CA, a 15-mm poststenotic CA aneurysm, and a 7-mm inferior PDA aneurysm. Given the high risk of rupture, urgent endovascular coil embolization of the CA aneurysm was performed first. Although the pain initially improved, severe symptoms recurred, suggesting a neurogenic etiology involving celiac plexus compression. Nine days after embolization, the patient underwent laparoscopic median arcuate ligament release with celiac neurolysis, which provided immediate relief. However, residual stenosis of the CA subsequently caused recurrent ischemic pain. Percutaneous transluminal angioplasty (PTA) was then performed, fully restoring antegrade flow and resolving all symptoms. At the 8-year follow-up, the patient remained asymptomatic with sustained patency of the CA. Notably, the untreated PDA aneurysm regressed spontaneously from 7 to 2 mm on follow-up CT 2 months after hemodynamic normalization and remained stable thereafter. CONCLUSIONS: This report illustrates the efficacy of a staged hybrid strategy-consisting of aneurysm embolization, surgical decompression with neurolysis, and PTA-for managing MALS complicated by multiple aneurysms. The restoration of antegrade celiac flow was associated with the normalization of collateral hemodynamics, subsequent resolution of ischemic symptoms, and the long-term spontaneous regression of the collateral PDA aneurysm.

Source: Surgical Case Reports

DOI: 10.70352/scrj.cr.26-0021