A case of negative computed tomography in liver transplant recipient with medium arcuate ligament syndrome (MALS). When to discard radiology in favor of surgical experience?

Abstract

Introduction: MALS, also known as celiac axis compression syndrome or Dunbar syndrome, is a rare and nonspecific disorder, when the median arcuate ligament compresses the celiac trunk due to the abnormal position of either the celiac trunk or the median arcuate ligament. Diagnosis of MALS is confirmed with positive findings on computer tomography (CT) or magnetic resonance angiography combined with duplex ultrasonography (USG). MALS is treated with the surgical release of the median arcuate ligament and celiac ganglionectomy. Case: 41 year old female underwent a liver transplantation for unresectable epithelioid hemangioendothelioma. Following the transplantation, abdominal USG and CT showed no flow within the left and right hepatic arteries. No evident stricture in 3D CT reconstruction was found. Complete thrombosis of the common hepatic artery was assumed and the patient was retransplanted six days later. During retransplantation, blood flow through the initially thrombosed hepatic artery, was not achieved until the dissection of the median arcuate ligament. Conclusion: Duplex USG may be superior to CT for diagnosing MALS as it reveals real time images where functional compression may be the case. When patient performs full expiration, USG shows this compression, if present, on the celiac trunk. CT during full inspiration will commonly show undisturbed arterial alignment and blood flow. Early diagnosis and treatment of MALS is a graft saving procedure. The surgeon should bare in mind that it’s the patient we ought to treat and not the radiology.