A Case Undergoing Section of Median Arcuate Ligament and Bypass Surgery for Abdominal Angina

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.