Treatment of inferior pancreaticoduodenal arcade aneurysms in the setting of MALS: a 5-year experience

Presented During:

Tue, 3/20/2018: 3:54 PM  - 4:03 PM 
Los Angeles Convention Center  
Room: 410  

Final ID:



Original Scientific Research-Oral or Poster 


S Desai1, S Gupta2, A Nemcek3, S Resnick4


1Northwestern Feinberg School of Medicine, Chicago, IL, 2Northwestern University Feinberg School of Medicine, Chicago, IL, 3Northwestern Memorial Hospital, Chicago, IL, 4Northwestern University, Chicago, IL

First Author:

Shamit S Desai, MD  
Northwestern Feinberg School of Medicine
Chicago, IL


Suraj Gupta, MD  
Northwestern University Feinberg School of Medicine
Chicago, IL
Albert A. Nemcek Jr, MD, FSIR  
Northwestern Memorial Hospital
Chicago, IL
Scott A. Resnick, MD, FSIR  
Northwestern University
Chicago, IL

Presenting Author:

Shamit S Desai, MD  
Northwestern Feinberg School of Medicine
Chicago, IL


Median arcuate ligament syndrome (MALS) is a rare but often underdiagnosed cause of chronic celiac occlusion. Flow-related inferior pancreaticoduodenal arcade (IPDA) aneurysms can often be challenging to manage.


A retrospective review of a single institution EMR from 1/1/2011 to 1/1/2016 was performed. The database included cases of pancreaticoduodenal arcade aneurysm, MALS, or idiopathic celiac stenosis. Eighty-seven cases met primary criteria. MALS was present in 21 cases.


Of twenty-one (n=21) patients with aortography-confirmed MALS, IPDA aneurysm was present in 6 (29%; mean age 58.7 years). Median aneurysm size was 2.1 cm (1.6–3.2 cm). All cases presented symptomatically (6/6): 4 with retroperitoneal hemorrhage and 2 with acute abdominal pain. Additional visceral aneurysms other than IPDA (splenic, right phrenic, and gastroepiploic) were identified in 3/6 cases in addition to IPDA aneurysm. Overall, 9/9 (100%) aneurysms were treated successfully (6 coil embolization, 2 coil/plug embolization, and 1 coil/stentgraft) and without procedure-related complications. All cases terminated with preserved collateral flow to the celiac axis.

MALS with chronic abdominal pain was successfully managed in 7/21 [33%, mean age 58 (36–84) years] cases via surgical ligament release. Overall, 5/21 (24%) cases of MALS were incidentally identified post-hepatic transplant on routine surveillance imaging (sonography or MR angiography) [24%; mean age 57 (43–69) years] and confirmed with subsequent aortography. Overall, 0/5 cases demonstrated incidental visceral aneurysms.


IPDA aneurysms seen in the setting of MALS can be treated using endovascular techniques with a high success rate. MALS is likely underdiagnosed and asymptomatic relative to true prevalence, as demonstrated by high relative incidence in orthotopic hepatic transplant surveillance imaging.

Abstract Categories:

Arterial Interventions: Other


median arcuate ligament syndrome (MALS)
Visceral artery aneurysms