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Median arcuate ligament syndrome

What's new

The European Society for Vascular Surgery (ESVS) has published updated guidelines on the management of mesenteric artery and vein diseases, including median arcuate ligament syndrome (MALS). MALS should be considered in highly selected patients with otherwise unexplained chronic abdominal symptoms and celiac artery stenosis or occlusion due to external compression. Duplex ultrasound of the mesenteric arteries during both inspiration and expiration is recommended as the first-line investigation for suspected MALS. Surgical intervention may be considered in selected patients, with laparoscopic or video-assisted retroperitoneal celiac artery release being the preferred approach. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of median arcuate ligament syndrome are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2025), the Society for Vascular Surgery (SVS 2021,2020), and the European Association for Gastroenterology, Endoscopy and Nutrition (EAGEN/CIRSE/NVMDL/HSGO/UEG/DMIS/ESGAR 2020).
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Screening and diagnosis

Diagnosis: as per ESVS 2025 guidelines, consider evaluating for MALS in highly selected patients with otherwise unexplained chronic abdominal symptoms and celiac artery stenosis or occlusion due to external compression, as characterized below:
postprandial pain associated with dietary modification, unexplained weight loss, or unexplained diarrhea
external compression of the celiac artery causing a ≥ 70% stenosis demonstrated by two imaging techniques (Duplex ultrasound, MRA, CTA, or digital subtraction angiography), which includes at least an inspiration and expiration CTA with 1 mm sections
abdominal ultrasound and EGD with no abnormalities.
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  • Differential diagnosis

Diagnostic investigations

Diagnostic imaging: as per ESVS 2025 guidelines, obtain duplex ultrasound of the mesenteric arteries during inspiration and expiration as the first-line examination in patients suspected of MALS.
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  • Screening for mesenteric aneurysms

Therapeutic procedures

Celiac artery stenting: as per CIRSE/DMIS/EAGEN/…/UEG 2020 guidelines, do not perform endovascular stenting of the celiac artery in patients with MALS (and no preceding adequate celiac artery release).
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Surgical interventions

Celiac artery release: as per ESVS 2025 guidelines, provide multidisciplinary management at specialized centers for patients with suspected MALS.
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