Analysis of Patients with Celiac Artery Compression: Distinguishing Characteristics of Patients with and without Median Arcuate Ligament Syndrome (MALS)
Meagan Kozhimala1, Shin Mei Chan1, Gabe Weininger1, Brandon Sumpio2, Sisi Zheng1, Sean Harris1, Louis Levine3, Bauer Sumpio1
1Surgery, Yale University, New Haven, Connecticut, United States, 2Surgery, MGH, Boston, Massachusetts, United States, 3Medicine, Yale University, New Haven, Connecticut, United States
Objective: Analyze patients with a discharge diagnosis of celiac artery compression to compare patients with true MALS with those who did not.
Design: IRB-approved retrospective chart review
Setting: Tertiary Academic Center
Patients: 293 patients from 2000 to 2021 with a discharge diagnosis of celiac artery compression syndrome via ICD-9/10 code.
Main Outcome Measures Patient demographics, symptoms and imaging findings of the MALS (n=69) and no MALS (n=224) patients. Baseline characteristics and symptoms were compared with Fisher exact test for categorical variables and Wilcoxon rank sum test for continuous variables with significance defined as *p < 0.05.
Results: No significant difference in sex (60.8 vs 60.7% females), race or BMI (29.8 vs 29.0). No significant differences in gastrointestinal comorbidities or symptoms. MALS patients were younger (55.7 vs 68.1*) and were less likely to have diabetes (12.5% vs. 26.9%*), renal disease (4.6 vs 8.2*) and hypertension (41.5% vs. 70.3%*). Non MALS patients were more likely to have concomitant mesenteric atherosclerotic disease (61.9% vs. 14.0%*) and peripheral artery disease (39.7% vs. 15.0%*). Both MALS and non-MALS patients underwent imaging with either CT/MR/angiography but the MALS group had higher incidence of a "hook sign"? (57.4 vs 28.5%*) and significant celiac artery stenosis >50% (73.8 vs 46.9%*).
Contrary to conventional teaching, radiologic characteristics of the celiac artery are neither specific nor sensitive indicators for MALS. Of the patients with diagnosed celiac artery compression, the patients who did not have MALS were more likely to have the risk factors for atherosclerosis, ie, they were older with higher incidence of diabetes, hypertension, renal disease, mesenteric artery disease and peripheral arterial disease compared to the true MALS patients. The diagnosis of MALS requires correlation of both celiac anatomy with symptoms. A high index of suspicion combined with appropriate recognition of patient characteristics (i.e., atherosclerotic phenotype) are needed to increase the accuracy of diagnosis of MALS.
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