Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report.

Introduction And Importance: Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection.

Case Presentation: A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms.

Clinical Discussion: MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS.

Conclusion: It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.