Intraoperative measurement of pressure gradient in median arcuate ligament syndrome as a rationale for radical surgical approach.

BACKGROUND: Median arcuate ligament syndrome (MALS) describes clinical symptoms in patients with stenosis of the celiac artery due to external compression by the ligament. There is an ongoing debate, whether sole release of the median arcuate ligament warrants long-term relief of the symptoms. MATERIALS AND METHODS: Eight patients diagnosed with MALS underwent open surgical treatment beginning with the release of the ligament. Systemic pressure and pressure in the left gastric artery were measured before and after division of the median arcuate ligament and release of the celiac artery. In patients with persistent gradient above 15 mm Hg after the release a PTFE bypass was performed. RESULTS: After the release, the pressure gradient decreased from 66 ± 19 to 48 ± 14 mm Hg (p = .001) and therefore in all patients either an aorto-celiac bypass (n = 6) or aorto-hepatic bypass (n = 2) was created. Consequently, the gradient decreased to 7 ± 2 mm Hg (p = .0001). One month postoperatively, three patients were free of symptoms and the rest reported relief of symptoms. CONCLUSIONS: Release of the celiac artery resulted in insufficient decrease of pressure gradient, which was achieved by bypassing the segment with favorable mid-term outcome. We believe that the effect of the release should always be assessed to decide on subsequent treatment.

Intercondylar Route of Prosthetic Infragenicular Femoropopliteal Bypass Has Better Primary, Assisted, and Secondary Patency but Not Limb Salvage Rate Compared to the Medial Route.

Aim. To compare the differences between medial and intercondylar infragenicular femoropopliteal prosthetic bypasses in terms of their midterm patency and limb salvage rates. Methods. Ninety-three consecutive patients with peripheral arterial disease who underwent a simple distal femoropopliteal bypass using a reinforced polytetrafluorethylene graft were included in this retrospective study. The bypass was constructed in the intercondylar route in 52 of the patients (group A) and in 41 in the medial route (group B). Results. Median observation time of the patients was 12.7 (IQR 4.6-18.5) months. There were 22 and 24 interventional or surgical procedures (angioplasty, stenting, thrombolysis, thrombectomy, or correction of the anastomosis) performed to restore patency of the reconstruction in groups A and B, respectively (p = 0.14). The 20-month primary, assisted, and secondary patency rates and limb salvage rates were 57%, 57%, 81%, and 80% in group A compared to 21%, 23%, 55%, and 82% in group B (p = 0.0012, 0.0052, 0.022, and 0.44, resp.). Conclusion. Despite better primary, assisted, and secondary patency rates in patients with a prosthetic infragenicular femoropopliteal bypass embedded in the intercondylar fossa compared to patients with the medial approach, there is no benefit in terms of the limb salvage rate and the number of interventions required to maintain patency of the reconstruction.