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Spontaneous celiac artery dissection is uncommon. Abdominal pain is a common clinical presentation. Conservative medical treatments, endovascular interventions, and open surgery are used to treat spontaneous celiac artery dissection. A 49-year-old male patient visited our hospital, with back and subxiphoid pain that had persisted for 11 hours. He has been smoking 40 cigarettes a day for 20 years. The blood pressure was 180/100mmHg. Aortic computed tomography angiography (CTA) images revealed dissection of the celiac artery, common hepatic artery, left hepatic artery, right hepatic artery, and splenic artery. Urapidil hydrochloride and isosorbide dinitrate were administered to lower the blood pressure to approximately 110/70 mmHg. However, the back and subxiphoid pain persisted without relief. Angiography was performed and a vascular stent (BARD, LIFE STENT, VASCULAR, 8 × 60) was implanted into the celiac artery without involving the branches. Pain was immediately relieved after interventional therapy. The patient was discharged after 4 days. A subsequent aortic CTA after 10 months confirmed that the celiac artery dissection had still not reoccurred.

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Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare but significant cause of chronic abdominal pain resulting from the extrinsic compression of the celiac trunk. This condition typically manifests with symptoms such as postprandial pain, nausea, vomiting, and weight loss, often leading to a diagnostic challenge due to its mimicry of other abdominal disorders. Diagnosis is based on exclusion and requires a high index of suspicion combined with precise imaging findings. This case report presents a 44-year-old female patient presenting with chronic abdominal pain, diaphoresis, and nausea, underscoring the complexity and diagnostic challenge of MALS, highlighting the significance of early intervention to mitigate morbidity and novelty treatment utilizing robotic-assisted surgical techniques. This report aims to contribute to the understanding of clinical presentations, diagnostic challenges, and treatment modalities of Dunbar syndrome, especially the option of minimally invasive robotic-assisted surgery for the treatment of this condition.

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Median arcuate ligament (MAL) syndrome, otherwise known as celiac artery compression syndrome, is rare and is characterized by celiac artery compression by the median arcuate ligament. We report a unique case of MAL syndrome with recurrent myocardial infarction as the primary manifestation, and offer new pathophysiological insights. A man in his early 50s experienced recurrent upper abdominal pain, electrocardiographic changes, and elevated troponin concentrations, which suggested myocardial infarction. Contrast-enhanced computed tomography showed considerable celiac artery stenosis due to MAL syndrome. The patient was diagnosed with MAL syndrome and acute myocardial infarction. He declined revascularization owing to economic constraints, and opted to have conservative treatment with Chinese herbal extracts and medications. He succumbed to sudden cardiac death during a subsequent abdominal pain episode. The findings from this case show that MAL syndrome can present with recurrent myocardial infarction rather than typical intestinal angina symptoms. The pathophysiological link may involve intestinal and cardiac ischemia. An accurate diagnosis and appropriate management of MAL syndrome require careful evaluation and investigation.

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BACKGROUND: The detection of a stenotic celiac artery (CA) typically mandates intraoperative revascularization during pancreaticoduodenectomy (PD) to preserve liver perfusion. The impact of CA stenosis on postoperative outcomes is unclear. This study evaluates whether CA stenosis (CAS) is associated with increased postoperative complications. METHODS: We conducted a retrospective analysis of PD patients from February 2014 to February 2022. Preoperative imaging assessed the CA lumen, categorizing it as patent, <50%, or ≥50% stenosis. Patients with narrowed SMA were excluded. Complications were categorized using the Clavien-Dindo system, and statistical analyses identified outcome differences. RESULTS: We included 427 patients in the study. Of these, 52 had CAS, and 311 had no-vessel stenosis (NVS). The median age of the CAS and NVS groups was 68 and 65 years, respectively. Postoperatively, 17.6% of patients with CAS exhibited delayed gastric emptying (DGE) versus 25.3% in the NVS group. Postoperative pancreatic fistula (POPF) was found in 13.5% of patients with CAS, compared with 23.7% without stenosis. The median length of hospital stay was shorter for patients with CAS (9 days) than for those with CAS (12 days). Severity-based classifications indicated higher complications in the no stenosis group and a 33.0% readmission rate within 30 days compared with 21.2% in CAS patients. However, none of these differences were statistically significant. CONCLUSIONS: Critical stenosis of the CA does not significantly affect postoperative outcomes following PD, suggesting preoperative correction of the narrowed CA may not be necessary. Further research is needed to confirm these findings.

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The hook sign is a radiologic finding best appreciated on a sagittal view of the celiac artery with computed tomography (CT) that indicates compression of the celiac artery. It refers to the hooked-shape of the proximal celiac artery caused by extrinsic compression by the median arcuate ligament. When seen in a patient with concurrent abdominal symptoms, it suggests median arcuate ligament syndrome (MALS). We saw the sign in a 15-year-old male via duplex ultrasonography and abdominal CT. He underwent laparoscopic release of the median arcuate ligament and had full resolution of his symptoms at follow-up.

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BACKGROUND: Median arcuate ligament syndrome (MALS) is a neurovascular disorder characterized by gastrointestinal symptoms due to celiac artery and ganglion compression. Limited literature primarily focuses on adults. This study aims to characterize clinical and histopathologic findings in pediatric MALS. METHODS: Patients <18 years undergoing robotic MAL release, celiac ganglionectomy, and lymphadenectomy from 2020 to 2024 were evaluated. Clinical and histopathologic outcomes were analyzed. RESULTS: Twelve patients met inclusion criteria and were reviewed (15.7 ± 1.2 years, 75% female, BMI 20.9 [18.6-24.0] kg/m2). Comorbidities included depression/anxiety (83%), postural orthostatic tachycardia syndrome (POTS) (50%), gastroesophageal reflux disease (GERD) (50%), nutrition support (50%), mast cell activation syndrome (MCAS) (42%), hypermobile Ehlers-Danlos syndrome (hEDS) (42%), other vascular compression syndromes (33%). All patients who received preoperative celiac plexus block had temporary symptom relief (10/10). Mean operative time was 119.7 ± 22.4 min. No intraoperative complications, 30-day readmissions, reoperations, or complications occurred. Histopathologically, 92% had fibroadipose tissue, 100% had reactive lymph nodes, none had intraparenchymal nerves, and one had lipogranulomas. Median fibrosis scores were 1 [0.5-2] on H&E and 2 [1-2] on trichrome. Fibrosis score severity was not significantly associated with symptom improvement (χ2 = 3.67, p = 0.16). Median postoperative celiac artery velocity was 258.5 [192.5-350.5] cm/s with a median change of -80.5 [-106.1-+82.8] cm/s from preoperative 308.0 [229.3-344.0] cm/s (S = -5.0, p = 0.55). Those with lower preoperative velocities were more likely to have symptom improvement postoperatively (S = 19, p = 0.04). MALS symptoms improved in 83%; however, despite reporting "MALS pain" was improved, 64% (all female) had other comorbidities such as POTS, MCAS, hEDS, and colonic dysmotility contributing to other ongoing symptoms. CONCLUSION: Robotic MALS surgery is safe and effective in pediatrics. Clinical improvement rates and fibrosis scoring are comparable to adults; however, findings reveal challenges with multiple comorbidities contributing to separate symptoms that may continue postoperatively, particularly in females. We recommend a multidisciplinary team approach in addressing comorbidities and optimizing medical and surgical care. LEVEL OF EVIDENCE: IV.

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Background: Vascular Ehlers-Danlos syndrome has a high mortality rate due to hemorrhagic complications. Case Presentation: We report a case of vascular-type Ehlers-Danlos syndrome diagnosed due to rupture of multiple celiac aneurysms. The patient was a 25-year-old Japanese man with a history of a sigmoid perforation. He was admitted to a nearby hospital because of abdominal pain. On day 9 of hospitalization, the patient experienced shock. Enhanced abdominal computed tomography revealed a hepatic aneurysm and intra-abdominal bleeding, and the patient was transferred to our hospital. Emergency abdominal angiography revealed multiple aneurysms in the celiac, common, and right hepatic arteries. The right hepatic artery was considered responsible and was embolized. The patient had characteristic physical findings of the syndrome, aiding in confirming the genetic analysis of COL3A1 gene abnormality. Conclusion: Juvenile-onset colonic perforation and rupture of the celiac arteries are key findings in the suspicion of vascular-type Ehlers-Danlos syndrome.

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OBJECTIVE: Adequate proximal and distal seal zones are necessary for successful thoracic endovascular aortic repair (TEVAR). Often, the achievement of an adequate distal seal zone requires celiac artery (CA) coverage by endograft with or without preservation of CA blood flow. The outcomes of CA coverage without its flow preservation were studied only in small case series. This study aims to determine the difference in outcomes between CA coverage with vs without preservation of CA blood flow during TEVAR using a multi-institutional national database. METHODS: The Vascular Quality Initiative database was reviewed for all TEVAR patients distally landing in zone 6. The cohort was divided into TEVAR with vs without CA flow preservation. Demographic, clinical, and perioperative characteristics, as well as postoperative mortality, morbidities, and complications, were compared between the groups. Univariate and multivariate regression analyses were performed. RESULTS: Of 25,549 reviewed patients, 772 had a distal landing in Zone 6, 212 of which (27.5%) had TEVAR without CA flow preservation, whereas 560 (72.5%) underwent TEVAR with CA flow preservation. Indications for TEVAR were aneurysm in 431 (55.8%), dissection in 247 (32.0%), or other in 94 (12.2%) cases. Patients who underwent TEVAR without CA flow preservation had statistically significantly higher rates of 30-day mortality (11.3% vs 5.9%; P = .010), 30-day disease/treatment-related mortality (8.0% vs 4.3%; P = .039), as well as a tendency of increased intestinal ischemia requiring intervention (1.9% vs 0.5%; P = .077). After adjusting for potential confounders, CA coverage without flow preservation was associated with more than a two-fold increase in the overall 30-day mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.35-5.92; P = .006) and 30-day disease/treatment-related mortality (OR, 2.72; 95% CI, 1.11-6.72; P = .029). In a sub-group analysis based on disease pathology, these results persisted only in the aneurysm group (30-day mortality [OR, 2.36; 95% CI, 1.01-5.48; P = .047]; 30-day disease/treatment-related mortality [OR, 2.88; 95% CI, 1.08-7.67; P = .034]), whereas there was no significant association between CA flow preservation status and the endpoints in the dissection subgroup (30-day mortality [OR, 1.16; 95% CI, 0.22-6.05; P = .856], 30-day disease/treatment-related mortality [OR, 0.90; 95% CI, 0.16-5.19; P = .911]). CONCLUSIONS: CA coverage during TEVAR without preservation of its blood flow is associated with significantly higher mortality in patients with aortic aneurysm, but not dissection. In patients with aortic aneurysm, CA flow should be preserved during TEVAR whenever feasible, whereas in patients with dissection, it may be safe to cover CA without preservation of its flow. Prospective studies should be done to confirm these findings and compare the open vs endovascular revascularization techniques on outcomes.

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Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, celiac axis syndrome, or celiac artery compression syndrome, is caused by a band of tissue called the median arcuate ligament that compresses the celiac artery and sometimes the celiac plexus too. MALS does not always cause symptoms, but when symptoms occur, surgery is the treatment of choice. This case report focuses on the case of a 27-year-old woman presenting with postprandial episodes of abdominal pain and vomiting accompanied by loss of weight, which was found to be MALS.

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This study aimed to identify the clinical characteristics associated with spontaneous isolated dissection of superior mesenteric artery/celiac artery (SIDSMA/SIDCA). This observational study, conducted at Toranomon Hospital, Japan between 2009 and 2020, analyzed consecutive SIDSMA/SIDCA cases based on radiology data. The study compared clinical characteristics between symptomatic and asymptomatic patients with SIDSMA/SIDCA and investigated factors related to future vessel dilatation. Among 57 cases (44 SIDSMA, 17 SIDCA, and 4 both), the majority were male (87.7%), nearly half having hypertension (43.9%) and smokers (48.9%). Of those, 17 cases (29.8%) were symptomatic; abdominal pain (94.1%), back pain (23.5%), nausea (17.6%) and fever (5.9%). The symptomatic group was younger (52.6 ± 9.4 versus 67.2 ± 7.9 years, P < 0.001), had higher systolic and mean blood pressure (142.6 ± 20.0 versus 129.5 ± 16.5 mmHg, P = 0.017; 96.1 ± 14.6 versus 88.2 ± 17.7 mmHg, P = 0.038), a higher white blood cell count (9975 ± 5032 versus 6268 ± 1991 /µL, P = 0.012), and a higher LDL cholesterol level at diagnosis (129.7 ± 21.7 versus 87.2 ± 25.6 mg/dL, P = 0.002) than the asymptomatic group. The factors associated with future vessel dilatation included the presence of pseudo-lumen flow in the dissection vessel (73.9% versus 41.4%, p = 0.019) and a larger vessel diameter (13.5 ± 2.4 mm versus 11.5 ± 2.1 mm, p = 0.005) at diagnosis after multiple adjustments, pseudo-lumen flow was a predictor of future vessel dilatation (odds ratio, 4.80; 95% confidence interval, 1.11-20.75; p = 0.036). The study revealed that only 30% of SIDSMA/SIDCA cases were symptomatic. Symptomatic cases were generally younger and exhibited higher blood pressure and elevated white blood cell counts. These findings offer valuable insights for the acute diagnosis of SIDSMA/SIDCA.

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Median arcuate ligament syndrome (MALS, also known as celiac artery compression syndrome, celiac axis syndrome, celiac trunk compression syndrome, Dunbar syndrome, or Harjola-Marable syndrome) is a rare condition characterized by abdominal pain attributed to the compression of the celiac artery and celiac ganglia by the median arcuate ligament. Pain can occur post-prandially and may be accompanied by weight loss, nausea, or vomiting. Following angiographic diagnosis, current definitive treatment may include open or laparoscopic decompression surgery with celiac ganglion removal (if affected), which has been found to provide relief. In this case report, we outline a young female patient with a MALS diagnosis and subsequent surgery, but whose pain recurred in various stress-related instances even after surgical intervention. After a particular pain episode, osteopathic manipulative treatment (OMT) was applied, with a focus on restoring autonomic balance through the use of various gentle osteopathic treatment techniques. A significant reduction in pain was reported post-treatment, followed by complete pain resolution, indicating a great benefit to the incorporation of OMT into the treatment plan of MALS patients in future osteopathic practice.

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Gastrointestinal diseases pose problems to captive common marmosets. Therefore, knowledge of the anatomy of the arterial supply to the gastrointestinal tract is an important prerequisite for implementing appropriate veterinary care. The common marmoset's intestinal tract has a well-developed cecum specialized for the fermentative digestion of tree gums. This specialized gastrointestinal tract may have a unique pattern of arterial distribution. This study aimed to elucidate the species-specific gastrointestinal tract arterial anatomy of the common marmoset. We traced the celiac, cranial mesenteric, and caudal mesenteric arteries in six male and nine female common marmosets using the latex injection method. We found that the celiac artery gave rise to the left gastric, common hepatic, splenic, and caudal pancreaticoduodenal arteries. In addition to these arteries, the celiac artery gave origin to the middle colic or jejunal arteries in seven or one cases, respectively. The branches of the cranial mesenteric artery consisted of 3-6 arteries, including the middle colic, caudal pancreaticoduodenal, jejunal, right colic, ileocolic, and ileal arteries, as well as a common trunk of the ventral cecal and ileal branches, and the dorsal cecal and colic branches. In four cases, the cranial mesenteric artery gave rise to the jejunal, ileocolic, and ileal arteries. In one of the 13 cases, the celiac and cranial mesenteric arteries formed a common trunk. The caudal mesenteric artery branched into the left colic, sigmoid, and cranial rectal arteries in all the cases. These findings provide an anatomical basis for gastrointestinal veterinary care of common marmosets.

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Anticipating a wide range of morphological variations of arterial anatomy of foregut derivatives beyond the classical pattern, a precise understanding is pertinent to preoperative diagnosis, operative procedure and to avoid potentially devastating post-operative outcome during various traumatic and non-traumatic vascular insult of foregut. The study aimed to revisit the morphological details and update unusual configurations of arteries of foregut to establish clinico-anatomical correlations. This study described the detailed branching pattern of coeliac trunk (CT) as principal artery of foregut with source & course of hepatic, gastric, duodenal and pancreatic branches in 58 cadaveric dissections. Based on morphology, different types and subtypes were made. The descriptions were explained using figures and pertinent tables. Among classical branches of CT, splenic artery was found as most stable whereas other two branches were found to be most variable with missing common hepatic artery in 11 cases. In addition to classical trifurcation (65.52%), different types of bifurcation (12.07%) and tetrafurcations (22.41%) of CT were observed. Regarding variations of hepatic arteries (27.59%), both non-classical origin and accessory hepatic branches were found. In case of gastric branches, more variant origins were seen with right gastric (50%) as compared to left gastric artery (34.48%). Other morphological variations included non-classical origin of gastro-duodenal artery (18.96%) along with presence of accessory pancreatic (17.13%) and duodenal arteries (6.38%). Awareness of anatomical variations regarding circulatory dynamics of foregut is worth knowing in order to facilitate successful planning of surgery involving upper abdominal organs with least complications.

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Celiac artery compression syndrome is not frequent in the pediatric population. The syndrome may entail long-standing abdominal pain, recurrent vomiting, bloating, weight loss, and an abdominal bruit, which in the case of our patient, was an incidental finding. Notably, patients may be asymptomatic.  Our patient is a 16-year-old male who presented with concerns about multiple, non-tender chest lymph nodes lasting for two weeks. He had also lost 80 lbs. over one year. On examination, however, an abdominal bruit was discovered, and a diagnostic workup was significant for celiac artery compression following a magnetic resonance angiography of the abdomen. Due to his significant weight loss and mediastinal lymphadenopathy, a chest computed tomography (CT) scan was done to rule out malignancy. The chest CT scan was reported as normal. Additionally, a renal duplex ultrasound was done to rule out renal artery stenosis, considering he had presented with elevated blood pressure; this was also unremarkable. Although this patient had a history of marijuana use, his assessment did not show marked dependence. Substance abuse and atherosclerotic vascular disease can be predisposing factors for celiac artery compression syndrome in older individuals. However, compression of the celiac trunk by the median arcuate ligament is a congenital anomaly more appreciated in younger age groups. The patient was referred to vascular surgery for possible median arcuate ligament release.

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Type A aortic dissection is a life-threatening emergency requiring prompt surgical treatment. The dissection itself and use of cardiopulmonary bypass can lead to further postoperative complications, including aortic branch occlusion, thrombosis, ischemia, and fatal end-organ damage. Celiac artery occlusion with consequent hepatic malperfusion is one feared complication of aortic dissection, which requires urgent surgical intervention. Optimal management of celiac artery dissection in the setting of type A aortic dissection has not yet been described in the literature. In this report, we describe a 39-year-old female patient with hypertension who was found to have celiac artery dissection and impending hepatic failure less than 48 hours after emergent ascending aortic replacement for type A aortic dissection. Placement of an ultrasound-guided endovascular celiac artery stent enabled reperfusion of the liver, ultimately saving the patient's life.

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BACKGROUND AND OBJECTIVES: Median arcuate ligament syndrome is caused by compression and stenosis of the celiac artery. Incision of the median arcuate ligament improves persistent abdominal symptoms. The study aimed at evaluating the outcomes in patients who underwent median arcuate ligament syndrome decompression using a self-report questionnaire. METHODS: This single-center retrospective study included patients with median arcuate ligament syndrome who underwent decompression surgery between April 2021 and February 2023. The medical records were retrospectively reviewed. RESULTS: Ten patients were included in the study. Laparotomy and laparoscopic surgeries were performed in seven and three patients, respectively. The median operation time was 147 minutes. The median hospitalization period after the operation was seven days. The degrees of celiac artery stenosis before and after surgery were compared and the per cent diameter stenosis did not significantly improve; five of 10 patients (50%) had > 50% stenosis in the celiac artery after the operation. Compared to the baseline, the scores of upper gastrointestinal symptoms significantly improved during the six months' period (p < 0.001). Additionally, we evaluated the influence of post-operative per cent diameter stenosis and divided the patients into two groups (≥ 50% vs, < 50%). The scores of upper gastrointestinal (GI) symptoms in both groups improved significantly from baseline. However, the symptomatic improvement at six months in the post-operative per cent diameter stenosis < 50% group was significantly greater than that in the ≥ 50% group (p = 0.016). The scores of lower gastrointestinal symptoms did not change significantly during the six-month period. CONCLUSION: Decompression surgery for median arcuate ligament syndrome could improve upper gastrointestinal symptoms regardless of the post-operative per cent diameter stenosis.

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OBJECTIVE: To evaluate the impact of celiac artery (CA) compression by median arcuate ligament (MAL) on technical metrics and long-term CA patency in patients with complex aortic aneurysms undergoing fenestrated/branched endograft repairs (F/B-EVARs). METHODS: Single-center, retrospective review of patients undergoing fenestrated/branched endovascular aortic aneurysm repairs and requiring incorporation of the CA between 2013 and 2023. Patients were divided into two groups-those with (MAL+) and without (MAL-) CA compression-based on preoperative computed tomography angiography findings. MAL was classified in three grades (A, B, and C) based on the degree and length of stenosis. Patients with MAL grade A had ≤50% CA stenosis measuring ≤3 mm in length. Those with grade B had 50% to 80% CA stenosis measuring 3 to 8 mm long, whereas those with grade C had >80% stenosis measuring >8 mm in length. End points included device integrity, CA patency and technical success-defined as successful implantation of the fenestrated/branched device with perfusion of CA and no endoleak. RESULTS: One hundred and eighty patients with complex aortic aneurysms (pararenal, 128; thoracoabdominal, 52) required incorporation of the CA during fenestrated/branched endovascular aortic aneurysm repair. Majority (73%) were male, with a median age of 76 years (interquartile range [IQR], 69-81 years) and aneurysm size of 62 mm (IQR, 57-69 mm). Seventy-eight patients (43%) had MAL+ anatomy, including 33 patients with MAL grade A, 32 with grade B, and 13 with grade C compression. The median length of CA stenosis was 7.0 mm (IQR, 5.0-10.0 mm). CA was incorporated using fenestrations in 177 (98%) patients. Increased complexity led to failure in CA bridging stent placement in four MAL+ patients, but completion angiography showed CA perfusion and no endoleak, accounting for a technical success of 100%. MAL+ patients were more likely to require bare metal stenting in addition to covered stents (P = .004). Estimated blood loss, median operating room time, contrast volume, fluoroscopy dose and time were higher (P < .001) in MAL+ group. Thirty-day mortality was 3.3%, higher (5.1%) in MAL+ patients compared with MAL- patients (2.0 %). At a median follow-up of 770 days (IQR, 198-1525 days), endograft integrity was observed in all patients and CA events-kinking (n = 7), thrombosis (n = 1) and endoleak (n = 2) -occurred in 10 patients (5.6%). However, only two patients required reinterventions. MAL+ patients had overall lower long-term survival. CONCLUSIONS: CA compression by MAL is a predictor of increased procedural complexity during fenestrated/branched device implantation. However, technical success, long-term device integrity and CA patency are similar to that of patients with MAL- anatomy.

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Blood flow to the active muscles and arterial blood pressure (ABP) increase during dynamic exercise, whereas blood flow to inactive organs (e.g., splanchnic organs and inactive limbs) declines. Aging leads to exaggerated ABP responses to exercise in females, but whether this is related to greater splanchnic vasoconstriction is unknown. This study sought to clarify the effect of aging in females on celiac artery blood flow during dynamic light-intensity exercise. Twelve healthy young females (YF: 20 ± 2 yr, mean ± SD) and 12 healthy older females (OF: 71 ± 4 yr) performed dynamic knee-extension and knee-flexion exercises at 30% of heart rate reserve for 4 min. The absolute changes from baseline (Δ) for mean arterial blood pressure (MAP), celiac artery mean blood flow (celMBF), and celiac vascular conductance (celVC) during exercise were calculated. ABP was measured using an automated sphygmomanometer, and celMBF was recorded by Doppler ultrasonography. The increase in MAP during exercise was greater in OF than in YF (YF: +14 ± 7 mmHg, OF: +24 ± 13 mmHg, P = 0.028). The celMBF decreased during exercise in both groups, but there was no significant difference in the response between YF and OF (YF: -93.0 ± 66.1 mL/min, OF: -89.6 ± 64.0 mL/min, P = 0.951). The celVC also decreased during exercise and remained lower than baseline during exercise. However, the response was not different between YF and OF (YF: -1.8 ± 1.0 mL/min/mmHg, OF: -1.5 ± 0.6 mL/min/mmHg, P = 0.517). These results demonstrate that aging in females has minimal influence on splanchnic artery hemodynamic responses during dynamic light-intensity exercise, suggesting that exaggerated ABP responses during exercise in OF are not due to greater splanchnic vasoconstriction.NEW & NOTEWORTHY During exercise, the splanchnic arteries vasoconstrict, contributing to blood flow redistribution and the blood pressure response. Blood pressure responses to exercise are exaggerated with aging in females; however, the physiological mechanism responsible has not been clarified. We show that celiac artery blood flow changes during light-intensity dynamic exercise do not differ with age in females. This indicates the exaggerated blood pressure to exercise with aging is likely not due to a difference in splanchnic vasoconstriction.

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INTRODUCTION: Median arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, leading to a typical symptom triad: postprandial abdominal pain, weight loss, nausea, and vomiting. CASE PRESENTATION: A 41-year-old female patient presented to our center with mild postprandial abdominal pain over the epigastric region, and bloating sensation. Ultrasonography of the abdomen showed multiple stones in the gall bladder lumen, and the computed tomography scan showed median arcuate ligament impingement along the proximal aspect of the celiac trunk causing moderate narrowing with post-stenotic dilation. Laparoscopic release of the median arcuate ligament with laparoscopic cholecystectomy was performed. DISCUSSION: The diagnosis of Median Arcuate Ligament Syndrome is based on the classical post-prandial symptoms and abdominal imaging technologies like Doppler ultrasonography, computed tomography angiography, or magnetic resonance angiography. Exclusion of other intestinal disorders should be considered before making the diagnosis. Celiac artery decompression through different means is the principle of treatment of this condition. CONCLUSION: The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have an established etiology. Celiac artery decompression by releasing the median arcuate ligament is the treatment.

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PURPOSE: The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS: A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS: Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION: The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT: This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.