What is the next step for a 39-year-old female, one year post-operative from median arcuate ligament (MAL) release and celiac plexus neurolysis, with recurrent pain and 60% stenosis of the proximal celiac artery on CT?

Management of Recurrent Pain After Median Arcuate Ligament Release with Celiac Artery Stenosis

For a patient with recurrent pain one year after median arcuate ligament (MAL) release and celiac plexus neurolysis who has 60% stenosis of the proximal celiac artery on CT, endovascular intervention with angioplasty and stenting of the celiac artery is the recommended next step.

Diagnostic Confirmation

Before proceeding with intervention, confirm the diagnosis with:

• Mesenteric angiography in lateral projection during both inspiration and expiration to:
  • Document dynamic worsening of stenosis on expiration
  • Evaluate for mesenteric collateralization 1
  • Assess hemodynamic significance of the stenosis

Treatment Algorithm

1. Endovascular intervention with celiac artery stenting

   • Indicated for patients with persistent symptoms after MAL release and residual celiac artery stenosis >30% 1
   • Provides complete symptomatic relief in up to 75% of patients 1
   • Prevents development of splanchnic artery aneurysms in the setting of persistent celiac stenosis 1

2. If endovascular approach fails or is contraindicated:

   • Consider surgical bypass or other forms of celiac artery revascularization
   • Studies show persistent resolution of clinical symptoms in 76% of patients who underwent revascularization in addition to decompression, compared to 53% with decompression alone 1

Evidence Supporting This Approach

The ACR Appropriateness Criteria specifically addresses this scenario, noting that endovascular stent placement after MAL release is appropriate when there is residual stenosis of the celiac artery >30% 1. With 60% stenosis in this patient, stenting is clearly indicated.

A multidisciplinary approach that includes stenting or surgical bypass as needed following surgical release has demonstrated high rates of symptomatic relief (75%) and freedom from reintervention (64%) at 6 months 1.

Important Considerations

• Timing of intervention: Endovascular intervention is typically performed after MAL release, as this patient has already had the ligament released but continues to have symptoms with significant stenosis
• Contraindication: Endovascular intervention alone (without prior MAL release) is not recommended due to the persistence of underlying extrinsic compression 1
• Monitoring: After intervention, follow-up imaging with duplex ultrasound should be performed to confirm improved arterial flow 2

Potential Complications

• Distal mesenteric embolization
• Branch perforation
• Dissection
• Stent dislodgement
• Stent thrombosis 1

Alternative Considerations

If the patient develops symptoms of gastric ischemia after initial treatment, proceeding with celiac axis stenting becomes necessary 3. In this case, the patient already has recurrent pain with documented stenosis, making stenting the appropriate next step.

The management of celiac artery stenosis is particularly important to prevent the development of pancreaticoduodenal artery aneurysms, which can be a serious complication of untreated celiac stenosis 4.