Stepwise management of median arcuate ligament syndrome with visceral artery aneurysm: Surgical ligament release followed by percutaneous transluminal angioplasty.

A woman in her 20s presented with an 8-year history of postprandial abdominal pain. Contrast-enhanced computed tomography revealed severe stenosis at the origin of the celiac artery, collateral circulation from the superior mesenteric artery, and an associated inferior pancreaticoduodenal artery aneurysm. Respiratory variation in celiac artery compression suggested median arcuate ligament syndrome. However, Doppler ultrasonography revealed an atypical hemodynamic pattern, with a lower peak systolic velocity during expiration than during inspiration. Two laparoscopic median arcuate ligament release procedures were performed, with additional perivascular neural tissue dissection during the second. Despite these interventions, residual celiac artery stenosis and elevated flow velocity persisted. Subsequent angiography and intravascular ultrasound confirmed focal residual stenosis. Percutaneous transluminal angioplasty was performed, which increased the minimal luminal diameter from 1.8 to 3.5 mm and improved flow dynamics. Prior to aneurysm treatment, a superior mesenteric artery occlusion test confirmed preserved antegrade flow from the celiac artery to the pancreaticoduodenal arcade. Following restoration of celiac artery inflow, coil embolization of the inferior pancreaticoduodenal artery aneurysm was successfully performed without ischemic complications, following which the patient's abdominal symptoms resolved. This case highlights a stepwise treatment approach that combines laparoscopic median arcuate ligament release and endovascular angioplasty to restore celiac artery inflow before aneurysm embolization in patients with median arcuate ligament syndrome complicated by visceral artery aneurysm.