Median Arcuate Ligament Syndrome in an Elderly Patient: A Symptomatic Post-stenotic Aneurysm and Systemic Atherothrombotic Disease.

Median arcuate ligament syndrome (MALS) is atypical in elderly patients, in whom it frequently coexists with severe atherosclerotic disease. We report the case of a 77-year-old male with marked mitral regurgitation who presented with intestinal claudication and malnutrition. CT angiography demonstrated MALS associated with a fusiform aneurysm of the celiac trunk with dissection, along with 60% atherosclerotic stenosis of the superior mesenteric artery. Given the limiting ischemic presentation, the patient underwent laparoscopic release of the ligament. The procedure was complicated by avulsion of the celiac trunk and massive hemorrhage, requiring conversion to laparotomy and definitive ligation of the vessel. Postoperatively, the patient developed mixed shock and irreversible diffuse mesenteric ischemia, culminating in death. This case illustrates the high risk of hemorrhagic complications and the difficulty of surgical decision-making when mechanical compression overlaps with extensive degenerative vascular fragility in an elderly patient.