Median Arcuate Ligament Syndrome Beyond the Classic Demographic: Celiac Artery Compression in a 62-Year-Old Man With Cardiovascular Risk Factors.

Median arcuate ligament syndrome (MALS) is an uncommon vascular condition caused by external compression of the celiac artery by the median arcuate ligament. Although it predominantly affects young women, late-onset presentations in older men have been reported and may reflect a different underlying mechanism. We present a 62-year-old man with dyslipidemia and a 20-pack-year smoking history who came to the emergency department with chronic postprandial epigastric pain. Physical examination was unremarkable. There was no abdominal bruit and no tenderness to palpation. Routine blood work showed a mildly elevated prothrombin time (14.4 seconds; international normalized ratio (INR): 1.30), an intermediate Fibrosis-4 (FIB-4) score of 2.39, and an elevated mean platelet volume (MPV) (10.5 fL). Contrast-enhanced CT of the abdomen and pelvis at Bayonne Medical Center demonstrated moderate to severe stenosis of the celiac axis origin related to acute angulation, with post-stenotic dilatation, and findings correlating with median arcuate ligament syndrome per the final radiology report. No other cause of his symptoms was identified. He was transferred to a tertiary care facility and underwent a minimally invasive median arcuate ligament decompression without complications. This case raises awareness of MALS as a diagnosis that should be considered in older male patients with cardiovascular risk factors and unexplained postprandial pain. The severity of stenosis in this case, beyond what is typically seen in young women with classic MALS, suggests that intrinsic atherosclerotic disease may compound extrinsic ligamentous compression in older patients.