Abstract P064: Case Report of Mals Surgery in Postural Orthostatic Tachycardia Syndrome

Background: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia associated with variety of symptoms like Headache, Abdominal discomfort, Dizziness/presyncope, Nausea, Fatigue, Lightheadedness, Sweating Sleep disorder, Tremor, Anxiety, Palpitations, Exercise intolerance. Median arcuate ligament syndrome (MALS, also known as celiac artery compression syndrome) is a condition characterized by abdominal pain, delayed gastric emptying, nausea, weight loss and other symptoms of autonomic dysfunction attributed to compression of the celiac artery and possibly the celiac ganglia by the median arcuate ligament. The researchers suggest that MALS should be considered in POTS patients who have persistent gastrointestinal symptoms. The purpose of this research is to study the celiac artery velocity in POTS patients. That led us to think about an operative procedure that can reduce POTS symptoms through MALS surgery. Patients and Method: We present the case of a 17 year old male with POTS symptoms not improving with medical management and celiac artery ultrasound positive for MALS.His celiac artery velocities was higher in Inspiration as well as Expiration and MALS is confirmed with CT angiogram.He underwent laparoscopic MALS surgery where the Median arcuate ligament is flipped thereby decreasing the extrinsic compression on the celiac artery. Results: There appears to be tremendous improvement in the patient’s symptoms after the surgery for MALS.His nausea had almost disappeared.Before surgery he had vomiting twice a week, after surgery he had vomiting four times in three months. His lightheadedness had disappeared. Bluish discoloration of arms and feet when he used to stand had disappeared in the hospital after the procedure. Sensations of hands had improved. Heat intolerance had improved. His Sleep and constipation improved. There was no much improvement in fatigue. Autonomic tilt table test is repeated after surgery to see if there is definite objective change, Heart rate in the first 10 minutes of tilt test before the surgery was >120bpm,Heart rate after the surgery was <100 bpm. Conclusions: Laparoscopic MALS surgery was found to be extremely helpful in relieving POTS symptoms with immediate results.

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Compression of the Celiac Artery by the Median Arcuate Ligament: Multidetector Computed Tomography Findings and Characteristics

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2015.01.001 ◽

2015 ◽

Vol 66 (3) ◽

pp. 272-276 ◽

Cited By ~ 8

Author(s):

Ozdil Baskan ◽

Emre Kaya ◽

Fatma Zeynep Gungoren ◽

Cengiz Erol

Keyword(s):

Computed Tomography ◽

Multidetector Computed Tomography ◽

Dominant Role ◽

Gastrointestinal Symptoms ◽

Celiac Artery ◽

Arterial Phase ◽

Control Group ◽

Median Arcuate Ligament ◽

Arcuate Ligament ◽

Atherosclerotic Changes

Purpose The prevalence of the celiac artery stenosis caused by median arcuate ligament (MAL) compression and its multidetector computed tomography (MDCT) characteristics were evaluated in patients who underwent abdominal MDCT procedures, retrospectively. Methods Totally 1121 patients who had abdominal MDCT with arterial phase or MDCT angiography of the abdominal aorta for various indications were analyzed for celiac artery compression by the MAL. Results Fifty (ie, 4.6%) patients showed typical MDCT features of MAL compression. Focal narrowing of the proximal celiac artery, a characteristic hooked appearance of the narrowed segment without calcification and atherosclerotic changes were diagnostic. Poststenotic dilatation was detected in 22 (44%) patients with MAL compression. The ratio of the stenosis of the celiac artery was between 35%-50% in 15 patients and 51%-80% in 35 patients. The gastroduodenal artery diameter of these patients was not significantly different from the asymptomatic control group. Conclusion MALS is an uncommon entity but it should be kept in mind in the presence of unexplained gastrointestinal symptoms. MDCT is a minimally invasive and plays a dominant role in the diagnosis of MAL compression especially with reformatted and 3-D reconstructed images.

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Celiac artery compression: Dunbar syndrome

Jornal Vascular Brasileiro ◽

10.1590/1677-5449.009418 ◽

2019 ◽

Vol 18 ◽

Cited By ~ 2

Author(s):

Giovanna Mezzalira Santos ◽

Luiz Marcelo Aiello Viarengo ◽

Marcos Danillo Peixoto Oliveira

Keyword(s):

Treatment Options ◽

Rare Condition ◽

Celiac Trunk ◽

Celiac Artery ◽

Interesting Case ◽

Median Arcuate Ligament ◽

Extrinsic Compression ◽

Arcuate Ligament ◽

Dunbar Syndrome ◽

Celiac Artery Compression

Abstract Celiac artery compression syndrome, also referred to as median arcuate ligament syndrome, celiac axis syndrome or Dunbar syndrome is a rare disorder consequent to extrinsic compression of the celiac trunk by the median arcuate ligament. Doppler ultrasound, multi-slice computed tomography angiography, magnetic resonance angiography, or invasive selective angiography can identify stenosis of the initial segment of the celiac artery and confirm diagnosis. Treatment options include open surgical or videolaparoscopic section of the median arcuate ligament and the fibers of the celiac plexus, or percutaneous transluminal angioplasty via an endovascular approach. We report herein an interesting case of a 38-year-old woman diagnosed with this rare condition and successfully treated with the surgical strategy.

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Median Arcuate Ligament Syndrome: A Case Report

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v21i2.24360 ◽

2018 ◽

Vol 21 (2) ◽

pp. 38-39

Author(s):

Akash Chitrakar ◽

Nirajan Subedi ◽

Ramesh Singh Bhandari

Keyword(s):

Computed Tomography ◽

Case Report ◽

Epigastric Pain ◽

Celiac Artery ◽

Celiac Axis ◽

Median Arcuate Ligament ◽

Median Arcuate Ligament Syndrome ◽

Celiac Ganglion ◽

Extrinsic Compression ◽

Arcuate Ligament

Median arcuate ligament (MAL) syndrome results from extrinsic compression of the celiac axis and or celiac ganglion by the MAL and diaphragmatic crura. A seventy five years lady presented with post prandial epigastric pain for 6 months. She had undergone considerable investigations for other diagnoses before an abdominal computed tomography (CT) revealed median arcuate ligament impinging celiac artery at its origin. She successfully underwent laparotomy and release of median arcuate ligament.

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Median arcuate ligament syndrome presenting with unintentional weight loss and epigastric pain

International Surgery Journal ◽

10.18203/2349-2902.isj20194452 ◽

2019 ◽

Vol 6 (10) ◽

pp. 3839

Author(s):

Mohammed Taher Mujahid ◽

Virendra Kumar Soni ◽

Rahul Saini

Keyword(s):

Weight Loss ◽

Rare Case ◽

Surgical Intervention ◽

Epigastric Pain ◽

Rare Condition ◽

Celiac Artery ◽

Median Arcuate Ligament ◽

Median Arcuate Ligament Syndrome ◽

Extrinsic Compression ◽

Arcuate Ligament

Median arcuate ligament syndrome is a rare condition characterized by extrinsic compression of celiac artery and celiac plexus by the median arcuate ligament. Patients typically present with chronic postprandial pain, nausea and occasionally, vomiting and weight loss. Treatment of this syndrome is laparoscopic or open surgical release of median arcuate ligament and gangliectomy. We report a rare case of median arcuate ligament syndrome in a patient who presented with abdominal pain and nausea. The patient was evaluated, investigated and planned for surgical intervention but the patient refused for treatment.

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Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20182308 ◽

2018 ◽

Vol 6 (6) ◽

pp. 2169 ◽

Cited By ~ 2

Author(s):

Rakshith Shetty ◽

K. Subramanyam ◽

Chinthu Sara Jacob

Keyword(s):

Epigastric Pain ◽

Celiac Trunk ◽

Celiac Artery ◽

Median Arcuate Ligament ◽

Median Arcuate Ligament Syndrome ◽

Rare Presentation ◽

Extrinsic Compression ◽

Arcuate Ligament ◽

Dunbar Syndrome

Median arcuate ligament syndrome (MALS) is a rare entity characterized by extrinsic compression of the celiac artery and symptoms of postprandial epigastric pain, nausea, vomiting, and weight loss mimicking mesenteric ischemia. The following case illustrates a rare cause of abdominal pain, where this young woman was found to have celiac trunk stenosis , secondary to compression of the trunk by the median arcuate ligament. She underwent a successful stenting to the ostial celiac trunk, thus reliving her symptomatically. Decompression of the celiac artery is the general approach. Usually post PTA, once revascularisation is achieved, 75% of the patients remain asymptomatic at follow up.

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Laparoscopic treatment for celiac artery stenosis caused by median arcuate ligament compression with Adachi V type vascular anomaly: a case report

Surgical Case Reports ◽

10.1186/s40792-021-01226-3 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Hiroshi Saito ◽

Koichiro Sawada ◽

Jyunichi Ogawa ◽

Masashi Hashimoto ◽

Masahiro Oshima ◽

...

Keyword(s):

Epigastric Pain ◽

Vascular Anomaly ◽

Celiac Artery ◽

Artery Stenosis ◽

Laparoscopic Treatment ◽

Median Arcuate Ligament ◽

Case Presentation ◽

Arcuate Ligament ◽

Major Vascular Injury

Abstract Background Median arcuate ligament syndrome (MALS), which results from compression of the median arcuate ligament (MAL), is a rare cause of abdominal pain and weight loss. Treatment is dissection of the MAL; however, the laparoscopic procedure is not yet established and it involves the risk of major vascular injury, especially in cases with an anomaly. Case presentation A 47-year-old man was evaluated at the hospital for epigastric pain. Contrast computed tomography scan revealed stenosis of the celiac artery origin due to the MAL. An Adachi V type vascular anomaly was also observed. Laparoscopic treatment was performed to release pressure on the celiac artery. Laparoscopic ultrasonography was used to less invasively confirm the release of the MAL. Despite a concomitant Adachi V type vascular anomaly, surgery was safely performed using the laparoscopic magnification view and intraoperative ultrasonography. Follow-up ultrasonography confirmed the celiac artery stenosis has not recurred. Conclusions A rare case of MALS with an Adachi V type vascular anomaly is presented and the laparoscopic treatment is detailed.

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Detailed anatomy and procedure of celiac artery decompression in median arcuate ligament syndrome

Langenbeck s Archives of Surgery ◽

10.1007/s00423-021-02195-9 ◽

2021 ◽

Author(s):

Kyoji Ito ◽

Nobuyuki Takemura ◽

Ryo Oikawa ◽

Fuyuki Inagaki ◽

Fuminori Mihara ◽

...

Keyword(s):

Celiac Artery ◽

Median Arcuate Ligament ◽

Median Arcuate Ligament Syndrome ◽

Arcuate Ligament

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Abstract 222: Nerve Conduction Study in Postural Orthostatic Tachycardia Syndrome

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.9.suppl_2.222 ◽

2016 ◽

Vol 9 (suppl_2) ◽

Author(s):

Chandralekha Ashangari ◽

Samreen F Asghar ◽

Sadaf Syed ◽

Amna A Butt ◽

Amer Suleman

Keyword(s):

Heart Rate ◽

Nerve Conduction Study ◽

Nerve Conduction ◽

Clinical Symptoms ◽

Orthostatic Intolerance ◽

Tibial Nerve ◽

Sensory Nerves ◽

Exercise Intolerance ◽

Postural Orthostatic Tachycardia Syndrome ◽

Medical Diagnostic

Background: Postural orthostatic tachycardia syndrome (POTS) is an autonomic disturbance characterized by the clinical symptoms of orthostatic intolerance, mainly light headedness, fatigue, sweating, tremor, anxiety, palpitation, exercise intolerance and near syncope on upright posture. These are relieved on lying down. Patients also have a heart rate >120 beats/min (bpm) on standing or increase their heart rate by 30 bpm from a resting heart rate after standing for 10 min. A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. The aim of this study is to demonstrate median, ulnar, peroneal, tibial nerve conduction results POTS patients. Methods: 177 patients were selected randomly from our clinic with POTS. Nerve conduction results of median, ulnar, peroneal, tibial nerves were reviewed from electronic medical records. Results: Out of 177 patients, 151 patients are females (85%, n=151, age 32.07±11.10), 26 patients are males (15%, n=26, age 29.08±17.40).Median nerve conduction results are 57.83 m/sec ±7.58 m/sec, Ulnar nerve conduction results are 56.62 m/sec ±6.85 m/sec, Peroneal nerve conduction results are 49.96 m/sec ±6.85 m/sec, Tibial nerve conduction results are 50.70 m/sec ±6.86 m/sec. Conclusion: The nerve conduction velocities tend to be within normal range in Postural Orthostatic Tachycardia Syndrome (POTS) patients.

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Surgical treatment of Dunbar syndrome

Jornal Vascular Brasileiro ◽

10.1590/s1677-54492013000100012 ◽

2013 ◽

Vol 12 (1) ◽

pp. 57-61 ◽

Cited By ~ 2

Author(s):

Luís Henrique Gil França ◽

Carla Mottin

Keyword(s):

Clinical Condition ◽

Epigastric Pain ◽

Celiac Trunk ◽

Celiac Artery ◽

Transluminal Angioplasty ◽

Celiac Artery Compression Syndrome ◽

Extrinsic Compression ◽

Arcuate Ligament ◽

Dunbar Syndrome ◽

Angioplasty And Stenting

Dunbar syndrome or celiac artery compression syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with an extrinsic compression upon the celiac axis near its takeoff from the aorta by fibrous diaphragmatic bands or sympathetic neural fibers. The authors report the case of a 70-year-old male patient presenting with nausea, epigastric pain, and weight loss. An aortography showed a compression of the celiac trunk. A preliminary attempt at percutaneous transluminal angioplasty and stenting proved unsuccessful. The patient became asymptomatic and his clinical condition improved after surgical release of the celiac trunk by partial section of the arcuate ligament of the diaphragm and with resection of the neural, fibrotic, and lymphatic tissues surrounding the aortic and visceral vessels. The purpose of this report is to discuss the indications and the therapeutic options of this syndrome.

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