Sgroi Michael D, Kabutey Nii-Kabu, Krishnam Mayil, Fujitani Roy M
Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA.
Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA; Department of Radiology, University of California, Irvine Medical Center, Orange, CA.
Ann Vasc Surg. 2015 Jan;29(1):122.e1-7. doi: 10.1016/j.avsg.2014.05.020. Epub 2014 Jun 12.
Median arcuate ligament syndrome (MALS) is a rare disorder defined by compression and narrowing of the celiac artery by the median arcuate ligament. The increased blood flow through the pancreaticoduodenal arcade can lead to the aneurysmal formation within the vessel. We report 3 cases of pancreaticoduodenal arterial aneurysms (PDAAs) in patients with MALS whose aneurysms were occluded, but celiac artery revascularization was not performed.
Case 1: Asymptomatic 61-year-old female with no past medical history was referred to vascular surgery for evaluation of a PDAA incidentally found on computed tomography (CT) scan. The patient was taken for laparoscopic division of the median arcuate ligament; however, the release was incomplete. This was followed by endovascular coil embolization of the PDAA without celiac revascularization. The patient tolerated the procedure well with no complications and the 1-year follow-up shows no signs of aneurysm recurrence. Case 2: A 61-year-old male found to have an incidental PDAA on CT scan. The patient was taken for coil embolization without median arcuate ligament release. At the 1-year follow-up, the patient continues to be asymptomatic with no recurrence. Case 3: A 56-year-old male presented with a ruptured PDAA. He was taken immediately for coil embolization of the ruptured aneurysm. Postoperatively, the patient was identified to have MALS on CT scan. Because of his asymptomatic history and benign physical examination before the rupture, he was not taken for a ligament release or celiac revascularization. He continues to be asymptomatic at his follow-up.
PDAAs secondary to MALS are very rare and most commonly diagnosed at the time of rupture, which has a mortality rate that reaches approximately 30%, making early identification and treatment necessary. Standard treatment would include exclusion of the aneurysm followed by celiac revascularization; however, these 3 cases identify an alternative approach to the standard treatment.
Celiac revascularization may not be necessary in the asymptomatic patient with a PDAA who has close follow-up and serial imaging.
正中弓状韧带综合征（MALS）是一种罕见疾病，由正中弓状韧带压迫和缩窄腹腔干动脉所定义。通过胰十二指肠动脉弓的血流量增加可导致血管内形成动脉瘤。我们报告3例MALS患者的胰十二指肠动脉动脉瘤（PDAA），这些动脉瘤已闭塞，但未进行腹腔干动脉血运重建。
病例1：一名61岁无症状女性，无既往病史，因计算机断层扫描（CT）偶然发现PDAA而转诊至血管外科。患者接受了腹腔镜下正中弓状韧带松解术；然而，松解不完全。随后对PDAA进行了血管内弹簧圈栓塞，未进行腹腔干血运重建。患者对手术耐受良好，无并发症，1年随访显示无动脉瘤复发迹象。病例2：一名61岁男性在CT扫描时偶然发现PDAA。患者接受了弹簧圈栓塞，未进行正中弓状韧带松解。1年随访时，患者仍无症状，无复发。病例3：一名56岁男性出现PDAA破裂。他立即接受了破裂动脉瘤的弹簧圈栓塞。术后，患者在CT扫描中被诊断为MALS。由于他在破裂前无症状且体格检查正常，未进行韧带松解或腹腔干血运重建。随访时他仍无症状。
继发于MALS的PDAA非常罕见，最常见于破裂时诊断，其死亡率约达30%，因此有必要早期识别和治疗。标准治疗包括排除动脉瘤，随后进行腹腔干血运重建；然而，这3例病例确定了一种替代标准治疗的方法。
对于有密切随访和系列影像学检查的无症状PDAA患者，可能无需进行腹腔干血运重建。
