Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography

Renal Artery Stenosis Due to Entrapment ()

BACKGROUND

Common etiologies of renovascular occlusive disease include atherosclerosis disease, developmental fibrotic conditions such as fibromuscular dysplasia (FMD), vasculitis. Extrinsic compression of the renal artery is a rarely reported phenomenon but can lead to similar clinical manifestations.

METHODS

We report recent experience with two patients who presented with extrinsic renal artery compression due to entrapment. Diagnosis was made with a constellation of findings on computed tomography angiography, dynamic duplex sonography, and catheter angiography. Both patients had hypertension and one had downstream subsegmental renal infarcts. The patients, both with right sided renal artery entrapment, were treated with open surgical decompression. Exposure was achieved via extended Kocher maneuver followed by mobilization of the right kidney and, in one patient, detachment of the right lobe of liver to allow circumferential exposure of the proximal right renal artery to the aorta. All entrapping tissue was circumferentially released.

RESULTS

Both operations were uncomplicated. Intraoperative sonography was used to confirm luminal patency of the released segments. Follow-up renal artery duplex in both patients demonstrated resolution of dynamic compression. Renal artery peak systolic velocity and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted and discontinuation of anticoagulation was possible in the patient who had recurrent episodes of renal infarct.

CONCLUSION

Extrinsic compression of renal artery by diaphragmatic crura is rare but should be considered in younger patients or otherwise any patients with no vascular risk factors when renovascular hypertension workup yields no demonstrable intrinsic disease. A high index of suspicion should be raised when an anomalously high origin of the renal artery or proximity to the diaphragmatic crura are seen on cross sectional imaging. Work-up should include dynamic imaging to assess compression of renal arteries during expiration. Open surgical or laparoscopic decompression of the involved renal arteries can be curative.

Renovascular hypertension secondary to renal artery compression by diaphragmatic crura

Median arcuate ligament syndrome is the result of celiac axis compression by the diaphragmatic crura. Although the celiac artery is the most common vessel to have compression, the renal arteries may also rarely be compressed by the crural fibers of the diaphragm, which may cause secondary hypertension. We present two cases of renovascular hypertension secondary to renal artery compression by the diaphragmatic crura. The first patient was treated with open decompression and wide resection of the crural fibers, and the second patient was decompressed laparoscopically. Neither case required renal artery reconstruction. Antihypertensives were discontinued in both patients postoperatively.

Retroperitoneal Hematoma: Rupture of Aneurysm in the Arc of Bühler Caused by Median Arcuate Ligament Syndrome

We herein report a case with aneurysm rupture in the arc of Bühler (AOB) caused by median arcuate ligament syndrome (MALS). The patient experienced a sudden onset of upper abdominal pain. Contrast-enhanced abdominal computed tomography (CT) showed an iso- to hyper-enhancing area mainly ranging from the dorsal aspect of the pancreatic head to the retroperitoneum around the right kidney. Abdominal angiography revealed marked stenosis in the origin of the celiac artery caused by MALS and a 7-mm saccular aneurysm in the AOB. Thus, we diagnosed the pain as having been caused by aneurysm rupture in the AOB due to MALS. The patient's symptoms and anemia also improved to normal range without surgery. Careful follow-up, considering possible recurrence of aneurysm at other sites in the future, is essential.

Celiac Trunk Stenosis Treated by Resection and Splenic Patch Reconstruction - A Case Report and Literature Review

Celiac trunk stenosis is a relatively common finding; the most common causes of this obstruction are median arcuate ligament syndrome, pancreatitis, local invasion of various malignancies originating from the pancreatic body, atherosclerosis or it can be idiopathic. However, most such cases remain asymptomatic for a long period of time, especially due to the presence of a patent collateral circulation originating from the superior mesenteric artery. In certain cases, the patient might become symptomatic, diffuse post-prandial pain being reported. We present the case of a 51-year-old patient diagnosed with celiac axis stenosis who was initially submitted to surgery with the preoperative suspicion of median arcuate ligament syndrome; however, the patient reported the persistence of the abdominal symptoms, leading to suspicion of idiopathic celiac axis stenosis. The patient underwent reoperation, the celiac trunk stenosis being resected, and the continuity of the vascular axis being established using a splenic artery patch. The postoperative course was uneventful, the patient presenting an adequate hepatic blood flow in the first day postoperatively.

Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery

OBJECTIVE

To evaluate the correlation between the gastroduodenal artery (GDA) haemodynamic changes and the degree of coeliac axis (CA) stenosis using phase-contrast MRI.

METHODS

The study was institutional review board approved, and written informed consent was obtained from patients included prospectively. A two-dimensional phase-contrast MRI was performed in 23 patients scheduled for a potential complex supramesocolic surgery, in a plane perpendicular to the GDA, during inspiration and expiration. The peak and mean velocities (V_p and V_m), mean flow rate (Q_m) and flow direction at inspiration and at expiration have been correlated with the degree of CA stenosis evaluated by CT.

RESULTS

13 of 23 patients presented CA stenosis due to the median arcuate ligament (34-80% of stenosis), 4 of them had associated atheromatous calcifications. V_p, V_m and Q_m of GDA presented a significant and linear relationship with the degree of CA stenosis, at inspiration as well as at expiration (r > 0.74, p < 0.001). Velocities and flow rates presented a different pattern depending on the degree of CA stenosis: <34% (n = 10), flow direction remained physiological with low velocities and flow rates; >60% of stenosis (n = 5), a reverse flow direction with increased velocities and flow rates were observed; variable patterns between 34% and 60%.

CONCLUSION

Phase-contrast MRI permits the evaluation of haemodynamic changes in GDA induced by CA stenosis, including median arcuate ligament compression, and could be of great interest in therapeutic decision making in supramesocolic surgery, such as liver transplantation or duodenopancreatectomy, by detecting haemodynamically significant stenoses. Advances in knowledge: Physiological phase-contrast MRI detects haemodynamically significant stenoses of the CA by evaluating haemodynamic parameters in the GDA. Physiological phase-contrast MRI demonstrates that flow in the GDA can be a direct marker of the real haemodynamic impact of a CA stenosis on the hepatic vascularization and could thus participate in the pre-surgical work-up of duodenopancreatectomy or hepatic graft, whereas existing pre-operative imaging are only morphological.

Multidetector Computed Tomographic Angiography for Optimal Cartography of the Visceral Abdominal Arterial Network: An Extensive Pictorial Review with Emphasis on Common and Uncommon Collateral Pathways, Complications and some Specific Syndromes

Multidetector computed tomographic angiography (MDCTA) is the new gold standard for diagnostic evaluation of the abdominal and/or mesenteric arteries. It is not invasive and provides a 2D and 3D global cartography of all abdominal arteries and that with only a limited amount of contrast media.

MDCTA allows the optimal diagnosis of single or multiple arterial stenosis and easily analyses sometimes very complex collateral pathways. It constitutes a major advance to plan the arterial visceral safety of major commonly performed abdominal surgical procedures such as aorto-iliac surgery, endovascular aneurysm repair (EVAR), but also complex pancreatic and gastrointestinal or colonic surgery. It also allows to plan the most optimal strategy for revascularization of the mesenteric system through percutaneous angioplasty, stent placement or surgical bypass.

This extensive pictorial review illustrates a large variety of situations which may be found during clinical practise. Single compression or stenosis of each digestive artery, combined and/or complex associations of stenosis and/or compressions of several arteries, secondary complications like aneurysms and classical but also sometimes unusual patterns of collateralization are richly illustrated. Specific syndromes comprising the median arcuate ligament syndrome (MALS) and the Leriche’s syndrome are also discussed.

Lessons learned from a case of multivessel median arcuate ligament syndrome in the setting of an Arc of Buhler

The median arcuate ligament (MAL) can rarely compress both the celiac axis and superior mesenteric artery. We present a case of a 70-year male who presented with isolated episodes of upper abdominal pain and diarrhea associated with sweats and nausea. Angiography images demonstrated complete occlusion of the celiac axis and compression of the superior mesenteric artery during the expiration phases. The celiac axis was reconstituted distal to its origin by a patent Arc of Buhler. Other reported cases of multivessel MALs have produced severe symptoms in young adults requiring surgical and/or endovascular intervention. In this case, our patient's Arc of Buhler was protective against more severe chronic mesenteric ischemia. We suggest that a patent Arc of Buhler is protective against symptoms in a single vessel MALs patient. A significant percentage of patients receiving surgical intervention for MALs do not have relief of symptoms. There should be a search for an Arc of Buhler before surgical management of patients suspected to have single vessel MALs.

Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man

Celiac Axis Compression Syndrome by the Median Arcuate Ligament is a very rare condition characterized by chronic postprandial abdominal pain (angina abdominis), nausea, vomiting, which occurs mostly in young patients. The main treatment is a surgical procedure that consists of the division of the arcuate ligament combined with the section of the close diaphragmatic crus and the excision of the celiac plexus. Actually laparoscopic management is feasible and safe.

An unusual case of left renal artery compression: a rare type of median arcuate ligament syndrome

Compression from median arcuate ligament was observed during multidetector 64-row computed tomography in a Caucasian 30-year-old female. The patient was referred for examination to exclude anatomical pathologies causing hypertension. The examination demonstrated that left renal artery, which had its origin in the chest (at the level of upper one-third of Th12), was compressed as it passed by median arcuate ligament of the diaphragm. In addition, aortic compression and kinked shape was also revealed.

Uncommon CT imaging of the hepatic falciform artery in patients presenting with very unusual variants of gastrointestinal arteries: report of two cases

The hepatic falciform artery (HFA) may be found in 68% of subjects in post-mortem dissections. It is well known by interventional radiologists who perform selective hepatic angiography. The reason essentially results from the potential supraumbilical skin complications which may produce by the distribution of chemotherapeutic agents through the HFA after transcatheter chemoinfusion or chemoembolization for liver tumors. Nevertheless, the spontaneous visualization of the HFA remains very unusual in current abdominal CT practice. We hereby report the demonstration of a patent HFA during conventional abdominal CT in two patients presenting without liver disease but in which very unusual variants of the gastrointestinal arteries were simultaneously found. The first patient had a common celiomesenteric trunk and the second had a severe compression of both the celiac trunk and superior mesenteric artery by the median arcuate ligament of the diaphragm. We shortly review the literature about these rare variants. We hypothesize that the HFA was spontaneously visible in our patients because of hypertrophy due supplying collateralization.

Nonatherosclerotic obstructive vascular diseases of the mesenteric and renal arteries

Nonatherosclerotic vascular diseases of the mesenteric and renal arteries are considered to occur less frequently than those caused by occlusive atherosclerotic disease. However, when present, they pose a significant diagnostic and therapeutic challenge. Such disorders include fibromuscular dysplasia, median arcuate ligament syndrome, the renal nutcracker syndrome, and some forms of acute and chronic mesenteric ischemia (embolic and thrombotic). This is a heterogeneous group of disorders with substantial differences in the pathogenesis and diagnostic approaches to these diseases. We provide an overview of the pathogenesis, clinical presentation, diagnosis, and current management of fibromuscular dysplasia, median arcuate ligament syndrome, and the renal nutcracker syndrome.

Clinical and radiologic review of uncommon cause of profound iron deficiency anemia: median arcuate ligament syndrome

Median arcuate ligament syndrome is an anatomic and clinical entity characterized by dynamic compression of the proximal celiac artery by the median arcuate ligament, which leads to postprandial epigastric pain, vomiting, and weight loss. These symptoms are usually nonspecific and are easily misdiagnosed as functional dyspepsia, peptic ulcer disease, or gastropathy. In this report, we presented a 72-year-old male patient with celiac artery compression syndrome causing recurrent abdominal pain associated with gastric ulcer and iron deficiency anemia. This association is relatively uncommon and therefore not well determined. In addition, we reported the CT angiography findings and three-dimensional reconstructions of this rare case.

Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization

We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.

Celiac artery compression syndrome: a radiological finding without clinical symptoms?

The aim of the paper is to determine the incidence of celiac artery compression (CAC) based on computed tomography (CT) scan and correlate the findings to the clinical presentation of patients presenting for CT scan in a hospital. Abdominal CT scans of patients were reviewed between September 2010 and November 2010. CAC was diagnosed if the celiac axis appeared to have a hook or U-shaped appearance with stenosis. The medical records of the patients were reviewed for gastrointestinal symptoms (abdominal pain, nausea, vomiting, constipation, diarrhea), as well as food fear and weight loss. Patients with CAC had lower incidence of symptoms compared with those without CAC (42.1 versus 65.3%, P = 0.042). A total of 450 patients were evaluated. In the end, 284 had both complete medical records and CT scans. The mean age for all patients was 51.3 ± 1.2 years. There were 124 men (42.6%) and 160 (57.4%) women. Nineteen (6.7%) patients had radiological evidence of CAC. CAC is not an uncommon CT finding in patients presenting for CT scan.

Median Arcuate Ligament Syndrome in a patient with Crohn's disease

INTRODUCTION

The Median Arcuate Ligament Syndrome is a rare condition characterized by postprandial abdominal pain, bowel function disorder and weight loss. We report the first case to our knowledge of Crohn's disease and Median Arcuate Ligament Syndrome.

PRESENTATION OF CASE

The patient was a 33 year-old female with a previous diagnosis of Crohn's disease. Acute postprandial abdominal pain affected the patient every day; she was, therefore, referred to US-Doppler and magnetic resonance angiography of the abdominal vessels and received a diagnosis of Median Arcuate Ligament Syndrome. Consequently, the patient was surgically treated, releasing the vascular compression. After the operation, she reported a complete relief from postprandial pain which was one of her major concerns. Subocclusive symptoms occurred after six months due to the inflammatory reactivation of the terminal ileitis.

DISCUSSION

The diagnosis of Median Arcuate Ligament Syndrome is mainly based on the exclusion of other intestinal disorders but it should be always confirmed using noninvasive tests such as US-Doppler, angio-CT or magnetic resonance angiography.

CONCLUSION

This case demonstrates that the Median Arcuate Ligament Syndrome could be the major cause of symptoms, even in presence of other abdominal disorders.

Surgical treatment of renal artery compression by diaphragmatic crus

Symptomatic compression of the renal artery by the diaphragmatic crus is a rare disorder. To our knowledge, renal artery compression by the diaphragmatic crus complicated with poststenosis aneurysm has not been reported. We present the case of a 28-year-old man with refractory hypertension. Extrinsic compression of the bilateral renal arteries and celiac artery and the aneurysm were proven by surgical exploration. We successfully performed left renal artery revascularization and renal autotransplantation in situ. Normal perfusion of the two bypass graft vessels was proven by computed tomography angiography.

Compression of the left renal artery and celiac trunk by diaphragmatic crura

Symptomatic compression of the celiac trunk by crura of the diaphragm is a rare disorder. Even more infrequent external compression of renal arteries is found. Although the indication for surgical therapy is controversially discussed in the literature for celiac artery compression syndrome, it is unequivocally for renal artery entrapment. We present the case of a young woman who was assigned to our hospital with arterial hypertension and stenosis of the left renal artery. After percutaneous transluminal angioplasty was performed, immediate recoil occurred. Therefore, the suspicion of entrapment by diaphragmatic crura was expressed. Additionally performed diagnostic procedures including computed tomography (CT)-angiography verified our suspicion. Surgical decompression of both vessels was successfully performed.

Clinical anatomy of celiac artery compression syndrome: a review

Anatomic variations are often responsible for a variety of clinical conditions. In this review we investigate compression of the celiac artery and the superior mesenteric artery by the median arcuate ligament (MAL), diaphragmatic crura, or the celiac nerve plexus. This clinical condition known as celiac artery compression syndrome (CACS) has proven controversial in definition and relevance. This condition was first described as chronic abdominal pain because of the mesenteric ischemia caused by extrinsic compression of the celiac artery. Dunbar and others presented surgical approaches to decompress the celiac artery by releasing the MAL. Definitive answers have been sought to classify and relieve the clinical symptoms patients experience postprandially. Persistent symptoms following surgical treatment for CACS have led investigators to question the existence of this disease. Advances in technology such as angiographic MRI and color duplex ultrasonography have refreshed the importance of considering compression of the celiac artery during differential diagnoses. Because of the varying anatomic etiologies of disease, it is not possible to pinpoint a single cause for CACS. Potential etiologies for compression of the celiac artery include a "high take off" origin of the celiac artery compressed by normal diaphragmatic crura and MAL, a normal origin of the celiac artery with long diaphragmatic crura and MAL, large bilaterally fused celiac ganglia (with or without the involvement of the superior mesenteric ganglia) compressing the celiac trunk, celiacomesenteric trunk compression by diaphragmatic crura and MAL, or combinations of the above mentioned entities. In this review we describe potential sources of compression of the celiac artery by regional structures and treatments of CACS in an effort to justify the relevance of CACS in modern medicine.

Median arcuate ligament syndrome: open celiac artery reconstruction and ligament division after endovascular failure

Median arcuate ligament syndrome (MALS) is a rare disorder resulting from extrinsic compression and narrowing of the celiac artery, and--less often--the superior mesenteric artery, by the relatively low insertion of the ligament and/or prominent fibrous bands or ganglionic periaortic tissue of the celiac nervous plexus. We report on a young woman who after three consecutive attempts of endovascular therapy with balloon angioplasty and stenting for MALS, each followed by gross symptom recurrence and a cumulative weight loss of 10 kg, underwent open surgical division of the ligament and reconstruction of the celiac artery. Despite the initial response of MALS to endovascular therapy, the extrinsic pressure exerted on the celiac artery by the surrounding dense fibrous/ganglionic tissue resulted in slippage of the stents and/or failure of their material. These findings militate against the use of balloon angioplasty and stenting primarily in patients with MALS without prior release of the extrinsic compression on the celiac (and/or superior mesenteric) artery by dividing the surrounding median arcuate ligament and/or ganglionic tissue with open or laparoscopic surgery.

Bilateral Renal Artery Entrapment by Diaphragmatic Crura

We present the case of a young man with compression of both renal arteries by the crura of the diaphragm. Correct diagnosis of renal artery entrapment is difficult but crucial. The investigations rely on an high index of suspicion and include Doppler ultrasound and spiral computed tomography angiography, which permits visualization of the diaphragm and its relationships with the aorta. This pathology, unlike common renal artery stenoses, requires surgical decompression and sometimes aortorenal bypass graft.

Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy

BACKGROUND

Celiac artery occlusion occurs in a small percentage of the population. Identifying this is critical in planning for pancreaticoduodenectomy. We reviewed 332 patients treated with pancreaticoduodenectomy, and identified 14 patients with celiac artery occlusion.

METHODS

Between 1988 and 2006, 14 (4%) of 332 patients treated with pancreaticoduodenectomy had median arcuate ligament syndrome with celiac artery occlusion (6 men, 8 women; mean age, 70 y; range, 38-80 y). Patients underwent preoperative imaging with computed tomography (n = 14) and angiography (n = 13).

RESULTS

Patients were diagnosed preoperatively (n = 13) and intraoperatively (n = 1) with celiac artery occlusion. Surgeries included classic pancreaticoduodenectomy (n = 12), pylorus-preserving pancreaticoduodenectomy (n = 1), median arcuate ligament release (n = 10), and vascular reconstructions (n = 4), with no surgical mortalities and postoperative complications in 6 patients (46%).

CONCLUSIONS

We report our experience of median arcuate ligament syndrome with celiac artery occlusion in 4% of our patients treated with pancreaticoduodenectomy. Patients underwent median arcuate ligament release, vascular reconstruction, and/or stenting. Angiography diagnosed celiac artery occlusion and allowed preoperative planning. Pancreatic surgeons must understand the importance of identifying celiac artery occlusion before resection to prevent severe complications.

CTA and MRA in Mesenteric Ischemia: Part 1, Role in Diagnosis and Differential Diagnosis

OBJECTIVE

CT angiography and MR angiography are the main techniques for the noninvasive diagnosis of mesenteric ischemia. High clinical suspicion and knowledge of the differential diagnostic possibilities in this clinical setting are essential for the correct interpretation of the scans.

CONCLUSION

CT angiography and MR angiography are well suited for the workup of patients when mesenteric ischemia is suspected.

Arcuate ligament vascular compression syndrome in infants and children

BACKGROUND

Arcuate ligament vascular compression syndrome has not been described previously in the pediatric or pediatric surgical literature. However, it is mentioned in the literature of vascular and general surgery and in journals of radiology and orthopedics. In this review, the intraoperative pathological anatomy and the principles of treatment for 8 children will be presented.

METHODS

The chart records and the anatomical sketches that were documented by the surgeon immediately after each procedure were analyzed retrospectively. In addition, preoperative courses and long-term follow-up (range, 3-18 years) were evaluated by a defined program.

RESULTS

The diagnosis of celiac artery compression by an arcuate ligament was suspected in children presenting with a history of several years of recurrent acute abdominal pain associated with a typical arterial bruit in the midline of the epigastric region.

CONCLUSIONS

Other diseases with recurrent abdominal pain and an arterial bruit must be excluded before making the decision for an operative intervention. Duplex ultrasound and angiography are possibly helpful tools to establish the respective diagnosis, but in the patients of the present series, these techniques neither confirmed compression of the celiac axis nor demonstrated decreased perfusion of the superior mesenteric artery. However, as the clinical symptoms clearly announce the disease, these diagnostic measures are not mandatory.

Renal artery entrapment by the diaphragmatic crus

The aim of this study is to describe renal artery entrapment (RAE) by the diaphragmatic crus and to elucidate the diagnostic and therapeutic approach to this entity. From 1995 to 2002, 15 patients (mean age 65) were found to have a RAE. They were investigated by CT scan (n=14) and/or MRA (n=2) for hypertension (n=7), chronic renal insufficiency (n=4) or aneurysms (n=4). The right (n=11) or the left (n=4) renal artery (RA) was involved. The compression was ostial (n=8) or truncal (n=7), and was > or = 50% in eight cases. The course of the RA along the aorta on angiographic views (n=8) or a concentric ostial stenosis in a patient free of atheromatous lesions (n=7) were two findings suggestive of an RAE. Seven RAEs were indicated for treatment but only three were treated, by mean of stenting. Among the latter, two stents were patent at 6-month follow-up and one evolved to restenosis because of a stent fracture. RAEs may be suspected on angiographic views and proved by cross-sectional imaging because of specific imaging features. It is of importance to detect this etiology of RA stenosis because angioplasty with stenting is probably not always advisable.

Pediatric applications of abdominal vascular Doppler: Part II

Ultrasound is a remarkably powerful and versatile modality for pediatric imaging, without requiring exposure to radiation or sedatives. By providing information on blood flow, Doppler sonography can reveal details about normal physiology and disease processes not discernable from gray-scale anatomic images alone. In part I, the basics of hemodynamics and effects on the Doppler waveform were discussed, along with clinical applications in hepatic disease. In part II, the application of Doppler in renal disease and in conditions affecting the deep abdominal vessels are discussed. The role of ultrasound contrast agents in pediatric Doppler imaging is briefly reviewed.

Anatomical investigation of the esophageal and aortic hiatuses: physiologic, clinical and surgical considerations

Precise knowledge about the anatomical constitution of the diaphragmatic pillars is essential to understand the physiologic, clinical and surgical roles of the esophageal and aortic hiatuses. Because anatomical descriptions found in the literature are dubious, we have decided to investigate this subject. Anatomical dissections and histologic sections of the right and left diaphragmatic pillars (diaphragma crura) from 43 human bodies were analyzed, comprising both non-fixed and fixed specimens. We have described a classification of the diaphragmatic pillars and their muscular branches, forming two basic arrangements (patterns I and II) around the esophageal and aortic hiatuses. Such anatomical and functional relationships between the esophagus and its diaphragmatic hiatus help explain why, during normal inspiration, a hiatal enlargement is observed first but is followed, thereafter, during deep inspiration, by a hiatal narrowing exerted by the contraction of the diaphragmatic pillars. Our results also show that the aortic hiatus does not seem to constitute a rigid ventral tendinous arc around the aorta that could impose any considerable degree of vascular compression, as suggested by other investigators. The present study provides anatomical data useful for a better understanding of gastroesophageal reflux physiology, antireflux surgery and abdominal angina.

Pediatric surgical image. A rare case: celiac artery compression syndrome in an asymptomatic child

Celiac artery compression syndrome is a rare disorder and characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs in symptomatic patients. This pathology is also known as median arcuate syndrome. The authors report a case of 12-year-old boy with severe celiac artery compression by the median arcuate ligament that was diagnosed by Magnetic Resonance Angiography (MRA) and color dupplex ultrasonography (US). There was only a bruit in the upper midepigastrium, and there were no gastrointestinal symptoms despite severe compression of celiac trunk. This clinicopathologic entity is very rare but represents severe complaints and clinical results caused by a decreased rate of the intestinal blood flow. In this report the authors suggest that the diagnosis of celiac artery compression should be considered in asymptomatic pediatric patients representing abdominal bruit or with palpated thrill in the upper epigastrium. In comparison with case reports present in the English-language literature, the patient reported on here is the youngest diagnosed.

Stenting of a renal artery compressed by the diaphragm

A 74-year-old man had a resistant hypertension with an increase in plasma aldosterone and active plasma renin levels, and an irregular appearance of the left kidney outline by ultrasound. The CT scan showed a stenosis of the left renal artery, which was pushed against the aorta by the left crus of the diaphragm. An angioplasty with placement of an autoexpansible stent was carried out with a good result on the arterial pressure level. After 3 years, the patient was re-hospitalised with severe hypertension. The CT scan demonstrated a compression of the stent by the left crus of the diaphragm, with good permeability of the artery downstream from the stent, and radiographic examination showed a fracture of the left renal artery stent. Thus, a reimplantation of the left renal artery in the aorta was carried out. Stenosis of the renal artery by fibres from a crus of the diaphragm is a rare cause of renovascular hypertension. Helicoidal angioscanner imaging is particularly useful to do the diagnosis. In the present case, renal angioplasty with stenting was complicated by a fracture of the stent that led to the surgery. Thus, when renal artery stenosis by a crus of the diaphragm is diagnosed, surgical treatment needs to be considered on a case-by-case basis in relation to the anatomy and the biological and functional data.

An uncommon association of abdominal vascular compression syndromes: Dumbar and Nutcracker

Abdominal pain associated with nausea and vomiting in a young patient led to a diagnosis of median arcuate ligament syndrome. The presence of mild haematuria was associated with a concomitant Nutcracker syndrome. Diagnosis was achieved by a computed tomography scan, which showed compression of the vessels of the coeliac axis and left renal vein. These syndromes are very rare, and their association in the same patient has not been described before. There is no relationship in the aetiology of these entities. In this report we discuss the diagnosis and therapeutic options, and review the literature.

Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation

Although celiac axis stenosis is a frequently encountered occlusive vascular disease, clinically significant ischemic bowel disease caused by celiac axis stenosis is rarely reported due to rich collateral circulation from the superior mesenteric artery (SMA). The most important and frequently encountered collateral vessels from the SMA in patients with celiac axis stenosis are the pancreaticoduodenal arcades and the dorsal pancreatic artery. Subtypes of collateral pathways via the dorsal pancreatic artery include a longitudinal pathway between the celiac branches and the SMA or its branches and a transverse pathway to either the splenic or gastroduodenal artery. A communicating channel between the right hepatic artery and the SMA can be a route for collateral circulation. Hepatic artery variants cause the development of unique collateral pathways that have different characteristics depending on the type of variant. These collateral pathways include intrahepatic interlobar collateral vessels, right gastric to left gastric arterial anastomoses, left hepatic to left gastric arterial anastomoses, and peribiliary arterial plexuses. Major collateral pathways in patients with celiac axis stenosis can be identified with spiral CT, and knowledge concerning this collateral circulation may be important for certain medical procedures such as interventional procedures for the management of hepatic tumors, pancreaticobiliary surgery, and liver transplantation.

Liver transplantation: preoperative CT evaluation

Liver transplantation is a successful therapeutic option for patients with chronic liver disease and liver failure in that 1-year survival is greater than 80%. Orthotopic transplantation is usually performed from a cadaveric or living adult donor. The necessary evaluation of recipients and donors prior to transplantation can be successfully performed with computed tomography (CT). CT is useful in determining clinically relevant information for recipients such as size of the caudate lobe, exclusion of advanced hepatocellular carcinoma and other malignancy, patency of the venous system, presence of perihepatic varices, patency of the celiac artery, exclusion of splenic artery aneurysm, and position of iatrogenic venous shunts. CT in living donors may help to determine clinically relevant information about variant hepatic arterial anatomy, source of the artery to segment IV, intraparenchymal anatomy of the hepatic veins and accessory hepatic veins, trifurcation of the portal vein or hepatic duct, liver volume, and fatty change of the parenchyma. Surgical approaches and the imaging findings that influence management are reviewed.

Embryologic and anatomic basis of esophageal surgery

The embryogenesis, congenital anomalies, and surgical anatomy and applications of the esophagus for benign and malignant processes are detailed in this article. Emphasis is placed on the role of embryology and the anatomy involved in surgical decisions.

Marked increase in flow velocities during deep expiration: A duplex Doppler sign of celiac artery compression syndrome

Symptoms of chronic mesenteric ischemia develop when the celiac artery is constricted by the median arcuate ligament of the diaphragm. Lateral aortography is the primary modality for diagnosing ligamentous compression of the celiac artery. However, duplex Doppler sonography performed during deep expiration can cause a marked increase in flow velocities at the compressed region of the celiac artery and suggest the diagnosis of celiac arterial constriction due to the diaphragmatic ligament.