Southern Association for Vascular surgery
Spring 2021 Newsletter

Vascular Specialist

Definitive Test to Establish Diagnosis of Median Arcuate Ligament Syndrome - Use of a Selective Intra-arterial Vasodilator

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VENKAT KALAPATAPU, AHSAN ALI*, TIFF SIRAGUSA*, KATHERINE PALM-CRUZ*, MOHAMMED M MOURSI, JOHN EIDT
UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES, Little rock, AR

Provocative Test to Determine the Physiologic Significance of Median Arcuate Ligament Syndrome - Use of a Selective Intra-arterial VasodilatorBackground: Definitive diagnosis of symptomatic median arcuate ligament compression of the celiac artery has been challenging at best. We believe that inducing vasodilatation of the superior mesenteric artery territory during angiography can reliably reproduce symptoms in patients with this syndrome and thereby establish definitive diagnosis.
Methods: A review of charts of patients who were referred for suspected chronic mesenteric ischemia between Jan, 2000 and Aug, 2007 was performed. Patients who underwent selective visceral angiography in the University hospital were identified. Mesenteric angiography was performed using selective catheterization of the celiac and the superior mesenteric artery. In patients with suspected median arcuate ligament syndrome and a patent SMA, an intra-arterial vasodilator was injected into the SMA. The response of the patient for reproduction of symptoms was noted. Follow up with method of revascularization in the positive group was recorded.
Results: 80 patients with a diagnosis of chronic mesenteric ischemia were identified. 45 of these underwent selective mesenteric angiography in the University hospital. 5 patients with possible median arcuate ligament syndrome underwent selective injection of arterial vasodilator (papaverine) into the superior mesenteric artery. 2 patients had immediate reproducible symptoms of abdominal pain. These patients underwent successful surgical revascularization of the celiac artery. The 3 patients with negative test were subsequently found to have other causes of their chronic abdominal pain.
Conclusion: Selective injection of an arterial vasodilator into the superior mesenteric artery can reliably reproduce symptoms related to celiac artery compression by median arcuate ligament. This is an extremely promising diagnostic tool in confirming symptomatic celiac artery compression from median arcuate ligament. This will immensely benefit in identifying patients who are likely to benefit from further intervention.


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