A Case Undergoing Section of Median Arcuate Ligament and Bypass Surgery for Abdominal Angina
The authors report a case of resection of median arcuate ligament and bypass surgery for abdominal angina with celiac artery (CA) stenosis and superior mesenteric artery (SMA) occlusion, focusing on the differential diagnosis of its etiology and treatment. A 71-year-old female complained abdominal p...
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| Published in | Japanese Journal of Vascular Surgery Vol. 33; no. 5; pp. 265 - 269 |
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| Main Authors | , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
JAPANESE SOCIETY FOR VASCULAR SURGERY
26.09.2024
特定非営利活動法人 日本血管外科学会 |
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| Online Access | Get full text |
| ISSN | 0918-6778 1881-767X |
| DOI | 10.11401/jsvs.24-00036 |
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| Abstract | The authors report a case of resection of median arcuate ligament and bypass surgery for abdominal angina with celiac artery (CA) stenosis and superior mesenteric artery (SMA) occlusion, focusing on the differential diagnosis of its etiology and treatment. A 71-year-old female complained abdominal pain, vomiting, and diarrhea for 3 months. Contrast-enhanced CT scans revealed thoracoabdominal aneurysm with thick mural thrombus and severe stenosis of the proximal CA (at 3 cm distal to its origin) with “hooked appearance” (alias, “hook sign”). The SMA was occluded and its distal was patent by collateral flow from the CA. From the above, median arcuate ligament syndrome was diagnosed. Because endovascular treatment was irrelevant due to aortic calcification and mural thrombus, semi-urgent surgical revascularization (bypass surgery) was performed via laparotomy. Intestinal ischemia was not improved despite resection of the median arcuate ligament, subsequently bypass surgery to the common hepatic artery (a branch of the CA) and the ileocolic artery (a branch of the SMA) was added. Blood flow of the grafts was sufficient, and postprandial abdominal pain due to intestinal ischemia was improved. |
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| AbstractList | The authors report a case of resection of median arcuate ligament and bypass surgery for abdominal angina with celiac artery (CA) stenosis and superior mesenteric artery (SMA) occlusion, focusing on the differential diagnosis of its etiology and treatment. A 71-year-old female complained abdominal pain, vomiting, and diarrhea for 3 months. Contrast-enhanced CT scans revealed thoracoabdominal aneurysm with thick mural thrombus and severe stenosis of the proximal CA (at 3 cm distal to its origin) with “hooked appearance” (alias, “hook sign”). The SMA was occluded and its distal was patent by collateral flow from the CA. From the above, median arcuate ligament syndrome was diagnosed. Because endovascular treatment was irrelevant due to aortic calcification and mural thrombus, semi-urgent surgical revascularization (bypass surgery) was performed via laparotomy. Intestinal ischemia was not improved despite resection of the median arcuate ligament, subsequently bypass surgery to the common hepatic artery (a branch of the CA) and the ileocolic artery (a branch of the SMA) was added. Blood flow of the grafts was sufficient, and postprandial abdominal pain due to intestinal ischemia was improved. The authors report a case of resection of median arcuate ligament and bypass surgery for abdominal angina with celiac artery (CA) stenosis and superior mesenteric artery (SMA) occlusion, focusing on the differential diagnosis of its etiology and treatment. A 71-year-old female complained abdominal pain, vomiting, and diarrhea for 3 months. Contrast-enhanced CT scans revealed thoracoabdominal aneurysm with thick mural thrombus and severe stenosis of the proximal CA (at 3 cm distal to its origin) with “hooked appearance” (alias, “hook sign”). The SMA was occluded and its distal was patent by collateral flow from the CA. From the above, median arcuate ligament syndrome was diagnosed. Because endovascular treatment was irrelevant due to aortic calcification and mural thrombus, semi-urgent surgical revascularization (bypass surgery) was performed via laparotomy. Intestinal ischemia was not improved despite resection of the median arcuate ligament, subsequently bypass surgery to the common hepatic artery (a branch of the CA) and the ileocolic artery (a branch of the SMA) was added. Blood flow of the grafts was sufficient, and postprandial abdominal pain due to intestinal ischemia was improved. われわれは，腹腔動脈（celiac artery: CA）狭窄・上腸間膜動脈（superior mesenteric artery: SMA）閉塞を認めた腹部アンギーナに対して，正中弓状靭帯切離・バイパス手術を行った1例を経験したので，動脈病変の病因の鑑別診断と治療法を中心に，若干の文献的考察を加えて報告する．症例は71歳女性で，3カ月前から心窩部痛を自覚し，その後腹痛・嘔吐・下痢を認めた．造影CT検査では，厚い壁在血栓を伴い瘤状拡張した胸腹部大動脈を認めた．CAの起始部より約3 cm末梢側のCA中枢部に鉤状の高度狭窄（hooked appearance・エコー所見のhook signに相当）を認めた．SMA起始部は閉塞し，末梢はCAからの側副血行路で造影されていた．以上よりSMA閉塞・正中弓状靭帯症候群によるCA狭窄と診断した．血管内治療は大動脈の石灰化と壁在血栓で困難と判断し，準緊急開腹手術を行うこととした．まず正中弓状靭帯を切離したが腸管虚血は改善せず，CAおよびSMAへのバイパス手術を追加した．グラフト血流は良好で腸管虚血は改善し，食後の腹痛は消失した． |
| Author | Nakamura, Yuhi Naito, Noritsugu Takagi, Hisato Hari, Yosuke Mori, Hisaya |
| Author_FL | 波里 陽介 中村 優飛 髙木 寿人 内藤 敬嗣 森 久弥 |
| Author_FL_xml | – sequence: 1 fullname: 森 久弥 – sequence: 2 fullname: 髙木 寿人 – sequence: 3 fullname: 中村 優飛 – sequence: 4 fullname: 波里 陽介 – sequence: 5 fullname: 内藤 敬嗣 |
| Author_xml | – sequence: 1 fullname: Nakamura, Yuhi organization: Department of Cardiovascular Surgery, Shizuoka Medical Center – sequence: 1 fullname: Mori, Hisaya organization: Department of Cardiovascular Surgery, Shizuoka Medical Center – sequence: 1 fullname: Naito, Noritsugu organization: Department of Cardiovascular Surgery, Shizuoka Medical Center – sequence: 1 fullname: Hari, Yosuke organization: Department of Cardiovascular Surgery, Shizuoka Medical Center – sequence: 1 fullname: Takagi, Hisato organization: Department of Cardiovascular Surgery, Shizuoka Medical Center |
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| References | 11) Chaum M, Shouhed D, Kim S, et al. Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome). Ann Diagn Pathol 2021; 52: 151732. 19) Escobar GA, Oderich GS, Farber MA, et al.; NACAAD Investigators. Results of the North American Complex Abdominal Aortic Debranching (NACAAD) registry. Circulation 2022; 146: 1149–1158. 14) Yuhn C, Hoshina K, Miyahara K, et al. Computational simulation of flow-induced arterial remodeling of the pancreaticoduodenal arcade associated with celiac artery stenosis. J Biomech 2019; 92: 146–154. 13) Ullah W, Mukhtar M, Abdullah HM, et al. Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circ J 2019; 49: 400–418. 7) Wang J, He Y, Zhao J, et al. Systematic review and meta-analysis of current evidence in spontaneous isolated celiac and superior mesenteric artery dissection. J Vasc Surg 2018; 68: 1228–1240.e9. 17) Sharrock M, Antoniou SA, Antoniou GA. Vein versus prosthetic graft for femoropopliteal bypass above the knee: a systematic review and meta-analysis of randomized controlled trials. Angiology 2019; 70: 649–661. 3) Biolato M, Miele L, Gasbarrini G, et al. Abdominal angina. Am J Med Sci 2009; 338: 389–395. 8) Xu Y, Bu W, Han X, et al. Current status of spontaneous isolated celiac artery dissection. Vascular 2023; 31: 678–685. 15) Nana P, Koelemay MJW, Leone N, et al. A systematic review of endovascular repair outcomes in atherosclerotic chronic mesenteric ischaemia. Eur J Vasc Endovasc Surg 2023; 66: 632–643. 18) Tanaka A, Oderich GS, Estrera AL. Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels. JTCVS Tech 2021; 10: 28–33. 1) Councilman WT. Three cases of occlusion of the superior mesenteric artery. Boston Med Surg J 1894; 130: 410–411. 5) Escárcega RO, Mathur M, Franco JJ, et al. Nonatherosclerotic obstructive vascular diseases of the mesenteric and renal arteries. Clin Cardiol 2014; 37: 700–706. 2) Goodman G. Angina abdominis. Am J Med Sci 1918; 155: 524–528. 6) Cunha E Sá D, Rosa A, Carmo GD, et al. Angina abdominal por displasia fibromuscular do tronco celíaco. Tratamento cirúrgico [Abdominal angina due to fibromuscular dysplasia of the celiac axis. Surgical management]. Rev Port Cir Cardiotorac Vasc 2013; 20: 41–44. 12) Scobie TK. Abdominal aortic aneurysms: how can we improve their treatment? Can Med Assoc J 1980; 123: 725–729. 4) Upshaw W, Richey J, Ravi G, et al. Overview of median arcuate ligament syndrome: a narrative review. Cureus 2023; 15: e46675. 10) Miura D, Hiwatashi R, Sakita M, et al. A new comprehensive ultrasonic diagnostic method for celiac artery compression syndrome that hybridizes “arterial compression hook sign” and peak systolic velocity. J Ultrasound 2021; 24: 289–295. 16) Alahdab F, Arwani R, Pasha AK, et al. A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia. J Vasc Surg 2018; 67: 1598–1605. 9) Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics 2005; 25: 1177–1182. |
| References_xml | – reference: 19) Escobar GA, Oderich GS, Farber MA, et al.; NACAAD Investigators. Results of the North American Complex Abdominal Aortic Debranching (NACAAD) registry. Circulation 2022; 146: 1149–1158. – reference: 12) Scobie TK. Abdominal aortic aneurysms: how can we improve their treatment? Can Med Assoc J 1980; 123: 725–729. – reference: 4) Upshaw W, Richey J, Ravi G, et al. Overview of median arcuate ligament syndrome: a narrative review. Cureus 2023; 15: e46675. – reference: 8) Xu Y, Bu W, Han X, et al. Current status of spontaneous isolated celiac artery dissection. Vascular 2023; 31: 678–685. – reference: 2) Goodman G. Angina abdominis. Am J Med Sci 1918; 155: 524–528. – reference: 9) Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics 2005; 25: 1177–1182. – reference: 14) Yuhn C, Hoshina K, Miyahara K, et al. Computational simulation of flow-induced arterial remodeling of the pancreaticoduodenal arcade associated with celiac artery stenosis. J Biomech 2019; 92: 146–154. – reference: 7) Wang J, He Y, Zhao J, et al. Systematic review and meta-analysis of current evidence in spontaneous isolated celiac and superior mesenteric artery dissection. J Vasc Surg 2018; 68: 1228–1240.e9. – reference: 3) Biolato M, Miele L, Gasbarrini G, et al. Abdominal angina. Am J Med Sci 2009; 338: 389–395. – reference: 18) Tanaka A, Oderich GS, Estrera AL. Total abdominal debranching hybrid thoracoabdominal aortic aneurysm repair versus chimneys and snorkels. JTCVS Tech 2021; 10: 28–33. – reference: 5) Escárcega RO, Mathur M, Franco JJ, et al. Nonatherosclerotic obstructive vascular diseases of the mesenteric and renal arteries. Clin Cardiol 2014; 37: 700–706. – reference: 10) Miura D, Hiwatashi R, Sakita M, et al. A new comprehensive ultrasonic diagnostic method for celiac artery compression syndrome that hybridizes “arterial compression hook sign” and peak systolic velocity. J Ultrasound 2021; 24: 289–295. – reference: 15) Nana P, Koelemay MJW, Leone N, et al. A systematic review of endovascular repair outcomes in atherosclerotic chronic mesenteric ischaemia. Eur J Vasc Endovasc Surg 2023; 66: 632–643. – reference: 17) Sharrock M, Antoniou SA, Antoniou GA. Vein versus prosthetic graft for femoropopliteal bypass above the knee: a systematic review and meta-analysis of randomized controlled trials. Angiology 2019; 70: 649–661. – reference: 1) Councilman WT. Three cases of occlusion of the superior mesenteric artery. Boston Med Surg J 1894; 130: 410–411. – reference: 6) Cunha E Sá D, Rosa A, Carmo GD, et al. Angina abdominal por displasia fibromuscular do tronco celíaco. Tratamento cirúrgico [Abdominal angina due to fibromuscular dysplasia of the celiac axis. Surgical management]. Rev Port Cir Cardiotorac Vasc 2013; 20: 41–44. – reference: 13) Ullah W, Mukhtar M, Abdullah HM, et al. Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circ J 2019; 49: 400–418. – reference: 11) Chaum M, Shouhed D, Kim S, et al. Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome). Ann Diagn Pathol 2021; 52: 151732. – reference: 16) Alahdab F, Arwani R, Pasha AK, et al. A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia. J Vasc Surg 2018; 67: 1598–1605. |
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| SubjectTerms | abdominal angina bypass surgery median arcuate ligament syndrome バイパス手術 正中弓状靭帯症候群 腹部アンギーナ |
| Title | A Case Undergoing Section of Median Arcuate Ligament and Bypass Surgery for Abdominal Angina |
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