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Sorber R, Bowen CJ, Radomski SN, Shalhub S. Prevalence and outcomes of select rare vascular conditions in females: A descriptive review. Semin Vasc Surg 2023; 36:571-578. [PMID: 38030331 DOI: 10.1053/j.semvascsurg.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Rare vascular conditions frequently pose a diagnostic and therapeutic dilemma for health care providers. Several of these conditions have distinct relevance to females populations but, due to their infrequency, there has been little reported on the outcomes of rare vascular conditions specifically in females populations. We performed a literature review of a selection of three rare vascular conditions known to either disproportionately affect females (median arcuate ligament syndrome and fibromuscular dysplasia) or have unique manifestations in females populations (vascular Ehlers-Danlos syndrome). We performed a descriptive review of the literature focused on these three vascular conditions and identified aspects of the current available research describing sex-based differences in prevalence, any pathophysiology explaining the observed sex-based differences, and the contribution of sex to outcomes for each disease process. In addition, considerations for pregnant females with respect to each rare vascular disease process are discussed.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Halsted 668, 600 N Wolfe Street, Baltimore, MD, 21287.
| | - Caitlin J Bowen
- Division of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Shannon N Radomski
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Halsted 668, 600 N Wolfe Street, Baltimore, MD, 21287
| | - Sherene Shalhub
- Division of Vascular Surgery, University of Oregon Health Sciences University, Portland, OR
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Borges AP, Antunes C, Donato P. Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization. Abdom Radiol (NY) 2023; 48:1415-1428. [PMID: 36801957 PMCID: PMC10115732 DOI: 10.1007/s00261-023-03844-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/29/2023] [Accepted: 01/30/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization. METHODS Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis. RESULTS MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases. CONCLUSIONS In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.
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Affiliation(s)
- Ana Paula Borges
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal.
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal.
| | - Célia Antunes
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging Department, Coimbra University Hospitals, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Academic and Clinical Centre of Coimbra, Coimbra, Portugal
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Romero-Velez G, Barajas-Gamboa JS, Pantoja JP, Corcelles R, Rodriguez J, Navarrete S, Park WM, Kroh M. A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study. Surg Endosc 2023; 37:140-147. [PMID: 35854125 PMCID: PMC9296109 DOI: 10.1007/s00464-022-09431-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. Appropriately selected patients can benefit from a laparoscopic or open median arcuate ligament release. Institutional series have reported the outcomes of open and laparoscopic techniques but there are no nationwide analysis comparing both techniques and overall trends in treatment. METHODS Cross-sectional study using the American College of Surgeons-National Surgical Quality Improvement Project from 2010 to 2020. Celiac artery compression syndrome cases were identified by International Classification of Diseases (ICD) codes and categorized as open or laparoscopic. Trends in the use of each technique and 30-day complications were compared between the groups. RESULTS A total of 578 open cases (76%) and 185 laparoscopic cases (24%) were identified. There was an increase adoption of the laparoscopic approach, with 22% of the cases employing this technique at the end of the study period, compared to 7% at the beginning of the study period. The open group had a higher prevalence of hypertension (26% vs 18%, p = 0.04) and bleeding disorders (5% vs 2%, p 0.03). Laparoscopic approach had a shorter length of stay (2.3 days vs 5.2 days, p < 0.0001), lower major complication rates (0.5% vs 4.0%, p = 0.02) and lower reoperation rates (0% vs 2.6%, p = 0.03). Overall mortality was 0.1%. CONCLUSION Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.
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Affiliation(s)
- Gustavo Romero-Velez
- Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code F20, Cleveland, OH, 44195, USA.
| | - Juan S Barajas-Gamboa
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Juan Pablo Pantoja
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ricard Corcelles
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Salvador Navarrete
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Woosup M Park
- Hearth and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mathew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Kim JE, Rhee PL. Median arcuate ligamentum syndrome: Four case reports. World J Clin Cases 2022; 10:1991-1997. [PMID: 35317133 PMCID: PMC8891776 DOI: 10.12998/wjcc.v10.i6.1991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/12/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligamentum syndrome (MALS) is a disease entity with unclear pathogenesis. If it is not considered in advance, the clinical diagnosis of the disease is very difficult because patients complain of digestive discomfort including pain. However, this characteristic is not specific to MALS. There have been no studies to assist in making a quick diagnosis. The aim of this case series was to recognize that MALS must be considered as a differential factor in the cause of abdominal pain.
CASE SUMMARY We described cases in which four patients complained of abdominal pain over a long period but in whom a diagnosis of MALS could not be made. If the gastroenterologist does not take into account abdominal pain in advance, the patient is considered an asymptomatic gallstone patient and has their gallbladder removed despite imaging evaluation. The patient may also be considered a psychiatric patient and may be administered psychiatric drugs over a long period. In all four cases in this report, the patients experienced abdominal pain. In three cases, the diagnosis was possible by the clinician’s judgment considering both clinical symptoms and imaging techniques shortly after the onset of symptoms. However, in one case that lasted over 20 years, a clear diagnosis was not possible. Even after complaining of colicky pain and performing a cholecystectomy, the diagnosis was made only after the symptoms persisted. In all four cases, the symptoms were relieved by neuromodulators.
CONCLUSION MALS is a rare disease and it is easy to miss because it is not malignant, but patients can suffer from pain over a long period. For the accurate diagnosis of a patient complaining of abdominal pain, the diagnosis must be differentiated. In addition, as there are asymptomatic patients, patients who need treatment should be carefully selected, and improvement with medical treatment can be expected. Large-scale studies are also needed.
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Affiliation(s)
- Ji Eun Kim
- Division of Gastroenterology, Samsung Medical Center, Seoul 06351, South Korea
| | - Poong Lyul Rhee
- Division of Gastroenterology, Samsung Medical Center, Seoul 06351, South Korea
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Abstract
Symptomatic celiac artery compression syndrome (CACS) or median arcuate ligament syndrome (MALS) is a controversial diagnosis that should be considered in patients with chronic abdominal pain of unknown etiology despite an extensive medical evaluation. Once suspected, patients should undergo mesenteric duplex ultrasound. Diagnosis is confirmed with elevated celiac artery velocities which normalize with deep inspiration followed by CT angiogram showing the typical "J-hook" conformation of the celiac artery. Patients should then undergo evaluation by a multi-disciplinary team to appropriately select and prepare patients for potential surgical treatment. Surgical options include release of the median arcuate ligament, with or without neurolysis of the celiac nerve plexus, and with or without concomitant revascularization procedures. Approaches can be open, laparoscopic, or robotic. Surgical treatment has an overall success rate of 70-80% with patients reporting improved abdominal pain and quality of life. Post-operatively, patients can have persistent or recurrent abdominal pain and should undergo re-evaluation for possible need for a revascularization procedure for stenosis of the celiac artery or celiac plexus block if the celiac artery flow is normalized. Additionally, some patients will have persistent pain consistent with functional gastrointestinal disorder (FGID) that will then require medical management. Psychiatric comorbidities have been identified as a predisposing factor that may predict poorer outcomes, and there are preliminary findings suggesting that patients with dysautonomia diagnoses may have worse outcomes as well.
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Narwani P, Khanna N, Rajendran I, Kaawan H, Al-Sam R. Median arcuate ligament syndrome diagnosis on Computed Tomography: what a radiologist needs to know. Radiol Case Rep 2021; 16:3614-7. [PMID: 34646405 DOI: 10.1016/j.radcr.2021.06.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/21/2022] Open
Abstract
Median arcuate ligament syndrome or celiac artery compression syndrome is one of the abdominal vascular compression syndromes due to compression of proximal celiac artery by the median arcuate ligament. The median arcuate ligament unites diaphragmatic crura on either side at the level of aortic hiatus. The ligament has a low insertion causing compression of the celiac artery resulting in clinical symptoms of postprandial pain and weight loss. It is a rare syndrome, detected incidentally on routine Computed Tomography abdomen and pelvis studies. We present a rare case of a 35-year-old female who presented with abdominal pain. She was evaluated by Computed Tomography scan of the abdomen and pelvis. Ultrasound Doppler of mesenteric vasculature helped detect celiac artery stenosis. A referral to the vascular surgery department was made; however, the patient was managed conservatively.
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Affiliation(s)
- Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - Vaishnavi Boppanna
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Zain A Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Denis McCarthy
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Skelly CL, Stiles-Shields C, Mak GZ, Speaker CR, Lorenz J, Anitescu M, Dickerson DM, Boyd H, O'Brien S, Drossos T. The impact of psychiatric comorbidities on patient-reported surgical outcomes in adults treated for the median arcuate ligament syndrome. J Vasc Surg 2018; 68:1414-1421. [PMID: 30064840 DOI: 10.1016/j.jvs.2017.12.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/28/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Median arcuate ligament syndrome (MALS) is an often overlooked, surgically correctable condition that mimics functional chronic abdominal pain. Patient-reported surgical outcomes are unpredictable in MALS. The objective of this study was to define the psychiatric comorbidities in a cohort of adults undergoing surgery for MALS and to determine whether these comorbidities are predictive of patient-reported quality of life (QOL) outcomes. METHODS A prospective observational trial was conducted between April 1, 2010, and December 31, 2015, at a single tertiary care hospital. Adults with a diagnosis of chronic abdominal pain in the setting of celiac artery compression were enrolled in a prospective Institutional Review Board-approved observational trial. Patients completed psychological assessments before surgery for MALS and at 6 months after surgery. The primary outcome was patient-reported health-related QOL (young adult version of the Pediatric Quality of Life Inventory). RESULTS A total of 51 patients (80% female; n = 41) with a mean age of 30.5 (±12.4) years were enrolled. Surgery significantly improved celiac artery hemodynamics in the entire cohort (P < .0001) as well as overall QOL (67.8 ± 14.6 [before surgery] vs 80.3 ± 13.7 [after surgery]; P < .001). Psychiatric diagnoses were common in this cohort, with 14 of 51 (28%) patients meeting criteria for a psychiatric diagnosis. There were no differences in the number of patients with psychiatric diagnoses between presurgical and postsurgical evaluations (14 [28%] vs 13 [26%]; P = .8). Exploratory analyses suggest that having a psychiatric diagnosis at the presurgical evaluation may predict significantly lower postsurgical QOL (R2 = 0.009; P = .01). CONCLUSIONS Surgery improves patient-reported QOL in adults treated for MALS. Psychiatric diagnoses are common in adults with MALS and predict worse patient-reported QOL outcomes.
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Affiliation(s)
- Christopher L Skelly
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago Medicine, Chicago, Ill.
| | - Colleen Stiles-Shields
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill; Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Grace Z Mak
- Department of Surgery, Section of Pediatric Surgery, University of Chicago Medicine, Chicago, Ill
| | - Christopher R Speaker
- Department of Surgery, Section of Pediatric Surgery, University of Chicago Medicine, Chicago, Ill
| | - Jonathan Lorenz
- Department of Radiology, University of Chicago Medicine, Chicago, Ill
| | - Magdalena Anitescu
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Ill
| | - David M Dickerson
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Ill
| | - Hope Boyd
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
| | - Setareh O'Brien
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
| | - Tina Drossos
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, Ill
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