What is the optimal treatment for a patient with more than 50 % proximal celiac artery stenosis caused by median arcuate ligament compression and a distal celiac artery dissection with a 14‑mm aneurysmal degeneration?

Treatment for Proximal Celiac Artery Stenosis with Median Arcuate Ligament Compression and Distal Celiac Dissection with Aneurysmal Degeneration

This patient requires urgent open surgical decompression of the median arcuate ligament with concurrent celiac artery revascularization (bypass grafting), combined with exclusion or repair of the 14-mm aneurysmal segment to prevent rupture and restore adequate mesenteric perfusion. 1, 2, 3

Rationale for Combined Surgical Approach

The presence of both median arcuate ligament compression AND a 14-mm aneurysmal dissection creates a life-threatening scenario that demands comprehensive surgical intervention rather than isolated treatment of either pathology:

• Aneurysmal dissections of the celiac artery carry significant rupture risk, particularly when exceeding 10-14 mm in diameter, with mortality rates approaching 30% when rupture occurs 4
• Endovascular stenting alone is absolutely contraindicated in this scenario because persistent extrinsic compression from the unreleasd ligament will cause stent fracture, migration, or slippage 1, 2, 3
• The aneurysmal degeneration itself is a direct consequence of the chronic ligament compression, which creates abnormal hemodynamic stress and high pressure at the celiac origin, predisposing to dissection and aneurysm formation 5

Surgical Algorithm

Step 1: Median Arcuate Ligament Release

• Perform complete surgical division and skeletonization of the celiac artery through open laparotomy (preferred) or laparoscopic approach 3, 6
• Include concurrent celiac ganglion sympathectomy to address the neurogenic component of symptoms 3
• Ensure complete decompression with visualization of all celiac branches 7, 6

Step 2: Assessment of Residual Stenosis

• After ligament release, evaluate for residual celiac stenosis >30%, which occurs in a substantial proportion of cases 2, 3
• If residual stenosis >30% persists, proceed immediately to revascularization 2, 3

Step 3: Management of Aneurysmal Dissection

• The 14-mm aneurysmal segment requires definitive treatment through either:
  • Aneurysm exclusion with aorto-celiac bypass grafting (preferred approach given the need for revascularization) 6
  • Direct aneurysm repair if technically feasible during the same operation 8
• Do not rely on coil embolization alone in this symptomatic patient with significant proximal stenosis, as this approach is only described in asymptomatic patients without need for celiac revascularization 4

Step 4: Revascularization Strategy

• Perform aorto-celiac bypass using autogenous or prosthetic graft to ensure adequate flow beyond the aneurysmal segment 6
• Combined decompression and revascularization achieves 76% persistent symptom resolution long-term, compared to decompression alone 3
• This approach simultaneously addresses the proximal compression, restores flow, and excludes the aneurysmal segment 2, 3

Critical Pitfalls to Avoid

• Never attempt endovascular stenting as primary therapy when median arcuate ligament compression is present, as the persistent extrinsic compression guarantees failure 1, 2, 3
• Do not treat the aneurysm in isolation without addressing the underlying ligament compression, as this leaves the hemodynamic abnormality that caused the aneurysm in the first place 5
• Do not perform incomplete ligament release, as this leads to persistent symptoms and potential aneurysm recurrence 4
• Avoid observation or conservative management given the presence of a 14-mm aneurysm with dissection, which carries substantial rupture risk 4

Expected Outcomes

• Open surgical decompression with standardized technique achieves 88.3% favorable clinical response rates 6
• Median hospital length of stay is 3 days with zero 30-day mortality in contemporary series 6
• Revascularization in addition to decompression is essential when residual stenosis >30% exists or when aneurysmal degeneration is present, as it provides durable symptom relief 2, 3
• 83.3% of patients achieve reduction of celiac stenosis to <50% after proper decompression 6

Postoperative Surveillance

• Annual duplex ultrasound and clinical evaluation are mandatory to monitor for recurrent stenosis or aneurysmal changes 8
• Long-term follow-up should assess for persistent symptom resolution and graft patency 3, 6