Is the MALS (Median Arcuate Ligament Syndrome) release procedure medically indicated for a patient with chronic abdominal pain and a positive response to a cervical plexus block, who also has compression of the celiac artery with expiration as shown on a mesenteric angiogram?

MALS Release Procedure is Medically Indicated for This Patient

Based on the documented celiac artery compression with expiratory worsening on angiography, chronic postprandial abdominal pain, and positive response to celiac plexus block, surgical release of the median arcuate ligament is medically indicated and should be approved. 1

Diagnostic Criteria Met

This patient fulfills the diagnostic criteria for MALS as defined by the American College of Radiology:

• Imaging confirmation: Mesenteric angiogram demonstrating celiac artery compression with expiration is the gold standard diagnostic finding 1
• Clinical symptoms: Chronic abdominal pain consistent with the typical MALS presentation 1
• Positive prognostic indicator: The 36-hour positive response to celiac plexus block is a validated predictor of surgical success, as this demonstrates the pain is sympathetically mediated via the celiac plexus 2

Evidence Supporting Surgical Intervention

The American College of Radiology 2022 guidelines provide clear support for surgical management:

• Surgical release achieves 84.6% symptomatic relief in patients with confirmed MALS 1
• Operative management produces 93% improvement compared to only 33% improvement with conservative management (counseling, analgesia, dietary modifications) 1
• Long-term outcomes show 76% persistent symptom resolution when revascularization is performed in addition to decompression 1

Critical Procedural Considerations

The procedure should include both ligament release AND evaluation for need of revascularization:

• Surgical release of the median arcuate ligament is the primary intervention 1, 3
• Celiac ganglion sympathectomy should be performed concurrently, as MALS has both vascular and neurogenic components 4, 5
• If residual celiac stenosis >30% persists after ligament release, additional revascularization (stenting or bypass) should be performed 1

Important Caveat About Endovascular-Only Approaches

Endovascular stenting alone without surgical ligament release is contraindicated and will fail due to persistent extrinsic compression causing stent slippage, fracture, or migration 3, 6. The literature consistently demonstrates that endovascular intervention must be accompanied by surgical release of the compressive ligament 1, 6.

Prognostic Factors in This Case

The positive celiac plexus block response is particularly significant:

• This demonstrates the pain is sympathetically mediated through the celiac plexus 2
• It serves as both a diagnostic tool and predictor of surgical outcomes 2
• The temporary relief followed by pain recurrence is the expected pattern that supports proceeding to definitive surgical release 2

Addressing the Absence of Mesenteric Collateralization

Patients without angiographic collateralization are MORE likely to benefit from surgical release than those with established collaterals 1. If this patient's angiogram showed no significant collateralization, this actually strengthens the indication for surgery.

Procedure Code Justification

While the insurance criteria mention "artery bypass graft procedure," the appropriate coding should reflect:

• Primary procedure: Median arcuate ligament release with celiac ganglion sympathectomy 3, 5
• Secondary procedure (if needed): Celiac artery revascularization via stenting or bypass if residual stenosis >30% is identified intraoperatively 1

This falls under the insurance criterion of "other clinically significant vascular abnormality that requires intervention" as MALS represents extrinsic compression requiring surgical correction 1, 3.

Surgical Approach Options

The American College of Radiology recognizes multiple surgical approaches as appropriate:

• Open surgical decompression (traditional approach) 7
• Laparoscopic release 7
• Robot-assisted release 7

All approaches should include careful celiac plexus sympathectomy in addition to ligament division 5.