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Viñas T, Melgar P, Alcázar C, Rodriguez-Laiz G, Ramia JM. Simultaneous treatment: Liver transplantation and median arcuate ligament syndrome. Cir Esp 2023; 101:581-584. [PMID: 37105366 DOI: 10.1016/j.cireng.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/14/2023] [Accepted: 02/21/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Tamara Viñas
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - Paola Melgar
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL, Alicante, Spain.
| | - Cándido Alcázar
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL, Alicante, Spain
| | - Gonzalo Rodriguez-Laiz
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL, Alicante, Spain
| | - Jose M Ramia
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL, Alicante, Spain; Universidad Miguel Hernández, Spain
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Bieniek PA, Katou S, Kraehling H, Masthoff M, Morgul H, Pascher A, Struecker B. Clinical impact of a celiac axis stenosis in patients undergoing hepatobiliary surgery. Langenbecks Arch Surg 2023; 408:279. [PMID: 37454337 PMCID: PMC10350437 DOI: 10.1007/s00423-023-03003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Celiac axis stenosis (CAS) often is an incidental finding in terms of diagnostic for hepatobiliary surgery since most cases remain asymptomatic. It remains unclear whether CAS is a risk factor for postoperative complications after hepatobiliary surgery. Therefore, the aim of this study was to evaluate the impact of an asymptomatic CAS on the postoperative morbidity and survival of patients undergoing hepatobiliary surgery. METHODS We retrospectively analyzed CT scans and clinicopathological data of 250 consecutive patients undergoing hepatobiliary surgery between 2011 and 2018 in our tertiary center. We compared the postoperative course between patients with and without an incidental CAS as well as their overall survival. RESULTS CAS was caused by atherosclerotic stenosis in 16 (64%) patients, by ligamentous stenosis in 4 (16%) and by combined conditions in 5 cases (20%). Mean age of patients in the CAS group was significantly higher in comparison to patients of the non-CAS group (71.0 vs. 59.1 years, p < 0.001). Major hepatectomy was conducted in 40% of the CAS patients and 19.6% of non-CAS patients, respectively (p = 0.036). Interestingly, no statistically significant differences in postoperative morbidity (40 vs. 46.2%, p = 0.673) or in overall survival between the groups (41.3 vs. 51.9 months, p = 0.611) were observed. CONCLUSION Our analysis found no correlation between an asymptomatic celiac axis stenosis and postoperative complications or overall survival after hepatobiliary surgery. Which impact the incidental CAS may have in highly complex cases remains unclear. Further studies are needed to identify patients who benefit from CAS treatment before hepatobiliary surgery.
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Affiliation(s)
- Pawel A Bieniek
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Hermann Kraehling
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Haluk Morgul
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany.
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3
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Gates J. Invited Commentary. J Am Coll Surg 2023; 236:1091-1092. [PMID: 36919938 DOI: 10.1097/xcs.0000000000000680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Li SX, Fan YH, Tian GY, Lv GY. Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients. World J Gastrointest Surg 2022; 14:976-985. [PMID: 36185558 PMCID: PMC9521469 DOI: 10.4240/wjgs.v14.i9.976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce.
AIM To evaluate the feasible surgical management of MALS to reduce complications in OLT patients.
METHODS Data for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner.
RESULTS Eight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory.
CONCLUSION The preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.
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Affiliation(s)
- Shu-Xuan Li
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Ye-Hui Fan
- Department of The First Operation Room, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guang-Yao Tian
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Contemporary Management of Median Arcuate Ligament in Liver Transplantation. Transplant Direct 2022; 8:e1348. [PMID: 36569785 PMCID: PMC9771178 DOI: 10.1097/txd.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 12/27/2022] Open
Abstract
Median arcuate ligament (MAL) can impair arterial inflow during orthotopic liver transplantation (OLT). Furthermore, approaches to ensure optimal vascular inflow in the presence of MAL is not standardized. Methods We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL. Results The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention. Conclusions We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.
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Dembinski J, Robert B, Sevestre MA, Freyermuth M, Yzet T, Dokmak S, Regimbeau JM. Celiac axis stenosis and digestive disease: Diagnosis, consequences and management. J Visc Surg 2020; 158:133-144. [PMID: 33191149 DOI: 10.1016/j.jviscsurg.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
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Affiliation(s)
- J Dembinski
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France
| | - B Robert
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M-A Sevestre
- Vascular Medicine Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M Freyermuth
- Vascular Surgery Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - T Yzet
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - S Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation, Assistance Publique-Hôpitaux de Paris and Paris University, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France.
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Cassar N, Gregory S, Menon K. New variation of median arcuate ligament compression causing hepatic arterial hypoperfusion during liver transplantation. Hepatobiliary Pancreat Dis Int 2020; 19:394-395. [PMID: 31812365 DOI: 10.1016/j.hbpd.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 11/04/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Noel Cassar
- Institute of Liver Studies, King's Healthcare Partners, Denmark Hill Site, London SE5 9RS, UK.
| | - Stephen Gregory
- Institute of Liver Studies, King's Healthcare Partners, Denmark Hill Site, London SE5 9RS, UK
| | - Krishna Menon
- Institute of Liver Studies, King's Healthcare Partners, Denmark Hill Site, London SE5 9RS, UK
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Czigany Z, Boecker J, Morales Santana DA, Bednarsch J, Meister FA, Amygdalos I, Isfort P, Liebl M, Neumann UP, Lurje G. Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study. J Clin Med 2019; 8:jcm8040550. [PMID: 31018577 PMCID: PMC6518097 DOI: 10.3390/jcm8040550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/15/2019] [Accepted: 04/22/2019] [Indexed: 12/17/2022] Open
Abstract
Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Iakovos Amygdalos
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Peter Isfort
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Martin Liebl
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
- Department of Surgery, Maastricht University Medical Centers (MUMC), 6202 AZ Maastricht, The Netherlands.
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
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Sun X, Fan Z, Qiu W, Chen Y, Jiang C, Lv G. Median arcuate ligament syndrome and arterial anastomotic bleeding inducing hepatic artery thrombosis after liver transplantation: A case report. Medicine (Baltimore) 2018; 97:e10947. [PMID: 29923979 PMCID: PMC6023679 DOI: 10.1097/md.0000000000010947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
RATIONALE Median arcuate ligament (MAL) may compress the coeliac trunk inducing median arcuate ligament syndrome (MALS). MALS is a risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients. PATIENT CONCERNS A thin female complained about upper abdominal pain for two months. DIAGNOSES The patient was diagnosed as primary biliary cirrhosis. INTERVENTIONS The patient received two liver transplantations. During the first liver transplantation, the hepatic artery (HA) pulsations were normal. Doppler B ultrasonography showed normal blood flow in the HA in the first week. A 4 cm hematoma was detected in the first porta hepatis. On the ninth day, the hematoma had increased to 9 cm along with development of HAT. Exploratory laparotomy was performed. Bleeding at the site of arterial anastomosis was considered to be the reason for the hematoma. Doppler imaging revealed no blood flow in the liver. Computed tomography angiography demonstrated MALS. Salvage liver transplantation combined with dissection of MAL was performed. The maximum velocity of HA increased to 87 cm/s. OUTCOMES The patient was discharged from the hospital 17 days after the second transplantation. At discharge, the liver function was normal and Doppler showed good blood flow in the HA. LESSONS MALS can cause HAT after liver transplantation. Before the liver transplantation, we should use Doppler B ultrasonography and sagittal CT imaging to judge whether the patient is with MALS. Also, before arterial anastomosis in liver transplantation is conducted, we should observe the impacts on the HA caused by pre-blocking gastroduodenal artery, which determines if we are supposed to do MAL dissection or bridge HA with aorta.
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Brody F, Randall JA, Amdur RL, Sidawy AN. A predictive model for patients with median arcuate ligament syndrome. Surg Endosc 2018; 32:4860-4866. [DOI: 10.1007/s00464-018-6240-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022]
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Haquin A, Sigovan M, Si-Mohamed S, Mabrut JY, Manichon AF, Bakir M, Rode A, Boussel L. Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery. Br J Radiol 2017; 90:20160802. [PMID: 28124567 DOI: 10.1259/bjr.20160802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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 (Vp and Vm), mean flow rate (Qm) 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. Vp, Vm and Qm 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.
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Affiliation(s)
- Audrey Haquin
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Monica Sigovan
- 2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
| | - Salim Si-Mohamed
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France.,2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
| | - Jean-Yves Mabrut
- 3 Department of Surgery, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | | | - Melisa Bakir
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Agnès Rode
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Loïc Boussel
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France.,2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
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Uchida H, Sakamoto S, Matsunami M, Sasaki K, Shigeta T, Kanazawa H, Fukuda A, Nakazawa A, Miyazaki O, Nosaka S, Kasahara M. Hepatic artery reconstruction preserving the pancreaticoduodenal arcade in pediatric liver transplantation with celiac axis compression syndrome: report of a case. Pediatr Transplant 2014; 18:E232-5. [PMID: 25092155 DOI: 10.1111/petr.12329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2014] [Indexed: 12/16/2022]
Abstract
CACS is rare, although it has been reported to be a potential risk factor for hepatic artery thrombosis following LT. We herein present the case of a 14-yr-old male with stenosis of the origin of the celiac trunk. Preoperative CT and color ultrasonography showed narrowing of the proximal celiac artery. The patient underwent DDLT with standard arterial reconstruction without dividing the gastroduodenal artery. His postoperative course was uneventful, with an excellent hepatic artery flow on Doppler ultrasonography. Applying a meticulous preoperative evaluation and the appropriate surgical technique is crucial in patients with CACS.
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Affiliation(s)
- Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Eliahou R, Sosna J, Bloom AI. Between a rock and a hard place: clinical and imaging features of vascular compression syndromes. Radiographics 2012; 32:E33-49. [PMID: 22236908 DOI: 10.1148/rg.321115011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vascular compression syndromes are caused by the entrapment of vessels between rigid or semirigid surfaces in a confined anatomic space. Chronic entrapment may lead to arterial ischemia and embolism, venous stasis and thrombosis, and hematuria. These syndromes are usually seen in otherwise healthy young patients, among whom underdiagnosis is common. Most occurrences of vascular compression are associated with an underlying anatomic abnormality. In a small percentage of cases, other contributing factors, including repetitive microtrauma, may cause pathologic changes leading to the onset of pain and other symptoms of vascular and neural compression. Hence, the diagnosis must be based on both clinical and radiologic findings. Because some cases of vascular entrapment become symptomatic only when specific physical maneuvers are performed, dynamic diagnostic imaging methods are especially useful. Digital subtraction angiography has been the mainstay of imaging-based diagnosis for most vascular compression syndromes, but other methods (eg, color Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) are used with increasing frequency for initial diagnostic evaluation. Because vascular compression syndromes are caused by the external compression of vessels, endoluminal treatment alone is rarely adequate and surgical decompression is likely to be required for optimal and durable clinical benefit. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.321115011/-/DC1.
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Affiliation(s)
- Ruth Eliahou
- Department of Radiology, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel
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14
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Roseborough GS. Laparoscopic management of celiac artery compression syndrome. J Vasc Surg 2009; 50:124-33. [PMID: 19563960 DOI: 10.1016/j.jvs.2008.12.078] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 12/04/2008] [Accepted: 12/21/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Celiac artery compression syndrome (CACS) remains a controversial diagnosis, despite several reported series documenting therapeutic efficacy of CA decompression. Traditional therapy consists of open surgical decompression, but since 2000, five isolated case reports have been published in which CACS has been successfully treated with laparoscopic techniques. This approach was adopted as the sole initial therapy for CACS at the Johns Hopkins Hospital in 2002. This article reports the results of a unique surgical series that triples the reported worldwide experience with this therapy. METHODS Fifteen patients (median age, 40.6 years) diagnosed with CACS underwent laparoscopic decompression by a single vascular surgeon. CACS was diagnosed by digital subtraction angiography in 14 patients and computed tomography (CT) angiography in one patient, with images acquired in both expiratory and inspiratory phases of respiration. CA decompression was offered after the results of a thorough workup for other pathology were negative, including upper and lower endoscopy, CT scanning, gastric and gallbladder emptying studies, upper gastrointestinal series, and small-bowel follow-through studies. Indications in all patients were abdominal pain and weight loss (average, 9 lbs). The procedure consisted of laparoscopic division of the median arcuate ligament and complete lysis of the CA from its origin on the aorta to its trifurcation. RESULTS Between November 2002 and September 2007, 15 consecutive patients underwent laparoscopic CA decompression. Median length of follow-up was 44.2 months. There were no operative deaths. Four patients were converted intraoperatively to an open decompression, all for intraoperative bleeding; only one required a blood transfusion. Average operating time was 189 minutes, and the average length of stay was 3.5 days. CA intervention was required in six patients, including three intraoperative procedures (1 patch angioplasty, 1 celiac bypass, 1 percutaneous angioplasty) and six late procedures (2 percutaneous angioplasties, 3 percutaneous stents, 1 celiac bypass). One complication occurred, a severe case of pancreatitis that developed 1 week after discharge. On follow-up, 14 of 15 patients subjectively reported significant improvement, and one patient remains symptomatic with no diagnosis. CONCLUSION Laparoscopic decompression of the CA may be a useful therapy for CACS, but there is potential for vascular injury, and adjunctive CA intervention is often required. Surgeons should consider laparoscopic CA decompression as a therapeutic alternative for CACS and should participate in the care of patients with this diagnosis.
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Affiliation(s)
- Glen S Roseborough
- Division of Vascular Surgery, Johns Hopkins University, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Noorani A, Walsh SR, Cooper DG, Varty K. Entrapment syndromes. Eur J Vasc Endovasc Surg 2008; 37:213-20. [PMID: 19046647 DOI: 10.1016/j.ejvs.2008.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 10/27/2008] [Indexed: 02/07/2023]
Abstract
Entrapment syndromes represent a pathological process that vascular specialists encounter infrequently. However symptomatic patients are often young with impaired quality of life and successful treatment can produce great benefit, making knowledge of these conditions essential. The purpose of this review was to bring together the entrapment syndromes to understand and gain consensus on the aetiology, pathogenesis, diagnosis and modern management of these rare and interesting vascular disorders. This includes entrapment syndromes of the popliteal artery, superior mesenteric artery, coeliac artery, renal vein and iliac vein.
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Affiliation(s)
- A Noorani
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
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16
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Median Arcuate Ligament in Orthotopic Liver Transplantation: Relevance to Arterial Reconstruction. Transplant Proc 2008; 40:3532-5. [DOI: 10.1016/j.transproceed.2008.07.133] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 05/15/2008] [Accepted: 07/07/2008] [Indexed: 01/19/2023]
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Loukas M, Pinyard J, Vaid S, Kinsella C, Tariq A, Tubbs RS. Clinical anatomy of celiac artery compression syndrome: a review. Clin Anat 2007; 20:612-7. [PMID: 17309066 DOI: 10.1002/ca.20473] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies.
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