Chronic Mesenteric Ischemia in a 26-Year-Old Man: Multivessel Median Arcuate Ligament Compression Syndrome

Background: Chronic mesenteric ischemia (CMI) is a rare diagnosis for patients in their third decade of life. Other conditions can mimic the signs and symptoms of CMI, including median arcuate ligament syndrome (MALS), primary arteritides, and congenital anomalies. Here, we present the case of a 26-year-old man who presented with CMI and multivessel mesenteric occlusive disease. Methods: A 26-year-old man presented with a 6-month history of 40-pound weight loss, postprandial abdominal pain, and food fear. His physical examination showed a scaphoid abdomen with no tenderness. Findings from laboratory evaluation were normal. Computed tomography angiogram revealed celiac artery (CA) occlusion and >80% superior mesenteric artery (SMA) stenosis, with a large marginal artery of Drummond supplying collateral circulation. Results: A retroperitoneal exposure of the perivisceral aorta was performed. Surgical exposure revealed compression of both CA and SMA by the MAL. The total distance of caudal arterial displacement was >3 cm. Both the CA and SMA were chronically stenotic/occluded secondary to this compression. After division of the MAL, a retrograde aortoceliac and aortomesenteric bypass was performed for mesenteric revascularization. The patient recovered uneventfully and was discharged home on the third day after surgery tolerating a full diet. Conclusions: MALS is a pathologic entity that can affect more than the CA. This case demonstrates multivessel, mesenteric arterial insufficiency secondary to MALS sufficient to promote IMA collateralization of the SMA circulation. In young patients with CMI, multivessel MALS must be considered. In addition to MAL release, arterial revascularization may be necessary owing to stenoses from chronic compression.