Staged surgical treatment (laparoscopic and endovascular) of a patient with extravasal compression and atherosclerotic stenosis of the celiac trunk
AbstractWe herein report a clinical case concerning successful staged (laparoscopic and endovascular) treatment of an elderly patient with tandem celiac trunk stenosis due to extravasal compression (Dunbar syndrome) and atherosclerotic lesion.
A 65-year-old male patient was admitted to the Angiosurgical Department in July 2019 with complaints of episodes of loss of consciousness occurring after meals, lasting up to a minute and followed by a spontaneous complete recovery.
On examination (ultrasound duplex scanning of the iliac trunk, MSCT angiography of the thoracic and abdominal aorta), he was diagnosed as having a hemodynamically significant stenosis (up to 80%) of the ostial segment of the celiac trunk caused by compression of the median arcuate ligament of the diaphragm, as well as an atherosclerotic lesion of the ostium of the celiac trunk (up to 70%). A decision was made to perform two-stage surgical treatment – laparoscopic decompression of the celiac trunk by dissection of the arcuate ligament, followed by delayed stenting of the celiac trunk in the area of the atherosclerotic lesion, with a positive clinical effect obtained in the form of complete relief of symptoms.
Four years later, the patient’s control examination revealed asymptomatic in-stent restenosis (up to 60%) managed by endovascular angioplasty with a drug-coated balloon catheter.
In the presented clinical case, staged minimally invasive treatment (laparoscopic and endovascular) made it possible to avoid traumatic surgical procedures (laparotomy, direct dissection of the arcuate ligament of the diaphragm, and direct endarterectomy of the celiac trunk with patch plasty), hence decreasing the risks of intra- and postoperative complications and contributing to the reduction of rehabilitation time and rapid return of the patient to his usual way of life.
Funding. This work was financed within the framework of the RF Government Decree No. 220 and Agreement dated 30.06.2022 No. 075-15-2022-1110 on state support of scientific research carried out under the supervision of leading scientists.
Conflict of interest. The authors declare no conflicts of interest.
Authors’ contribution. Study conception and design – Moiseev M.K., Gamzatov T.Kh.; data collection and handling – Moiseev M.K., Gamzatov T.Kh., Kebryakov A.V.; draft manuscript preparation – Moiseev M.K., Gamzatov T.Kh.; manuscript revision – Moiseev M.K., Gamzatov T.Kh., Lodygin A.V., Ratnikov V.A., Gurevich V.S., Kashchenko V.A., Svetlikov A.V.
For citation: Moiseev M.K., Gamzatov T.Kh., Lodygin A.V., Svetlikov A.V., Ratnikov V.A., Gurevich V.S., Kashchenko V.A., Kebryakov A.V. Staged surgical treatment (laparoscopic and endovascular) of a patient with extravasal compression and atherosclerotic stenosis of the celiac trunk. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2023; 29 (4): 66–73. DOI: https://doi.org/10.33029/1027-6661-2023-29-4-66-73
Keywords:Dunbar syndrome; extravasal compression syndrome; compression stenosis of the celiac trunk; chronic mesenteric ischemia; atherosclerosis of the celiac trunk; median arcuate ligament of the diaphragm; laparoscopic decompression of the celiac trunk; balloon angioplasty; stenting of the celiac trunk
References
1. Shetty R., Subramanyam K., Jacob C.S. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. International Journal of Research in Medical Sciences. 2018; 6 (6): 2169–2171. DOI: https://doi.org/10.18203/2320-6012.ijrms20182308
2. Santos G.M., Viarengo L.M.A., Oliveira M.D.P. Celiac artery compression: Dunbar syndrome. Journal Vascular Brasileiro. 2019; 18: e20180094. DOI: https://doi.org/10.1590/1677-5449.009418
3. Terlouw L.G., Moelker A., Abrahamsen J., et al. European guidelines on chronic mesenteric ischaemia – joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterology Journal. 2020; 8 (4): 371–395. DOI: https://doi.org/10.1177/2050640620916681
4. Zeller T., Rastan A., Sixt S. Chronic atherosclerotic mesenteric ischemia (CMI). Vascular Medicine. 2010; 15(4), 333–338. DOI: https://doi.org/10.1177/1358863x10372437
5. Torres O.J.M., Gama-Filho O.P., Torres C.C.S., et al. Laparoscopic treatment of Dunbar syndrome: A case report. International Journal of Surgery Case Reports. 2017; 37: 230–232. DOI: https://doi.org/10.1016/j.ijscr.2017.06.056
6. Kim E.N., Lamb K., Relles D., et al. Median Arcuate Ligament Syndrome – Review of This Rare Disease. JAMA Surgery. 2016; 151 (5): 471. DOI: https://doi.org/10.1001/jamasurg.2016.0002
7. Roayaie S., Jossart G., Gitlitz D., et al. Laparoscopic release of celiac artery compression syndrome facilitated by laparoscopic ultrasound scanning to confirm restoration of flow. Journal of Vascular Surgery. 2000; 32 (4): 814–817. https://doi.org/10.1067/mva.2000.107574
8. Romero‑Velez G., Barajas‑Gamboa J.S., Pantoja J.P., et al. A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study. Surgical Endoscopy. 2023; 37 (1): 140–147. DOI: https://doi.org/10.1007/s00464-022-09431-3
9. Chen A.J., Yeh S., Dhindsa Y., et al. Outcomes of Median Arcuate Ligament Release: A Single Institution Retrospective Review. Annals of Vascular Surgery. 2023; 94: 296–300. DOI: https://doi.org/10.1016/j.avsg.2023.02.030
10. Khrucharoen U., Juo Y.-Y., Sanaiha Y., et al. Robotic-assisted laparoscopic median arcuate ligament release: 7-year experience from a single tertiary care center. Surgical Endoscopy. 2018; 32 (9): 4029–4035. DOI: https://doi.org/10.1007/s00464-018-6218-9
11. Lima F.V., Kolte D., Kennedy K.F., et al. Endovascular Versus Surgical Revascularization for Chronic Mesenteric Ischemia. JACC: Cardiovascular Interventions. 2017; 10 (23): 2440–2447. DOI: https://doi.org/10.1016/j.jcin.2017.09.033
12. Altintas Ü., Lawaetz M., de la Motte L., et al. Endovascular Treatment of Chronic and Acute on Chronic Mesenteric Ischaemia: Results From a National Cohort of 245 Cases. European Journal of Vascular and Endovascular Surgery. 2021; 61 (4): 603–611. DOI: https://doi.org/10.1016/j.ejvs.2021.01.003
13. Zacharias N., Eghbalieh S.D., Chang B.B., et al. Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure. Journal of Vascular Surgery. 2016; 63 (6): 1582–1587. DOI: https://doi.org/10.1016/j.jvs.2016.02.051
14. Van Dijk L.J., Noord D. van, de Vries A.C., et al. Clinical management of chronic mesenteric ischemia. United European Gastroenterology Journal. 2018; 7 (2): 179–188. DOI: https://doi.org/10.1177/2050640618817698
15. Goldman M.P., Reeve T.E., Craven T.E., et al. Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions. Annals of Vascular Surgery. 2017; 38: 29–35. DOI: https://doi.org/10.1016/j.avsg.2016.08.009
16. Kim E.N., Lamb K., Relles D., et al. Median Arcuate Ligament Syndrome—Review of This Rare Disease. JAMA Surgery. 2016; 151 (5): 471. DOI: https://doi.org10.1001/jamasurg.2016.0002
17. Jimenez J.C., Harlander-Locke M., Dutson E.P. Open and laparoscopic treatment of median arcuate ligament syndrome. Journal of Vascular Surgery. 2012; 56 (3): 869–873. DOI: https://doi.org/10.1016/j.jvs.2012.04.057