Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study.

Zoltan Czigany,Jan Bednarsch,Iakovos Amygdalos,Franziska Alexandra Meister,Ulf Peter Neumann,Georg Lurje,Joerg Boecker,Martin Liebl,Peter Isfort,Daniel Antonio Morales Santana

doi:10.3390/jcm8040550

Abstract

Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.

Highlights

Orthotopic liver transplantation (OLT) has evolved as the standard treatment for end-stage liver disease [1]
Extrinsic stenosis of the celiac axis owing to Median arcuate ligament compression (MALC) was found in 34 (12%) patients (Table 1)
In OLT, MALC may lead to arterial complications requiring an urgent surgical division of the median arcuate ligament (MAL) and thrombectomy

Summary

Introduction

Orthotopic liver transplantation (OLT) has evolved as the standard treatment for end-stage liver disease [1]. Despite standardization of the operative technique, hepatic artery thrombosis (HAT) remains a rare but dreadful complication following OLT [2,3,4,5,6]. Median arcuate ligament compression (MALC) is a rare medical condition caused by the extrinsic compression of the celiac axis by means of the fibrous bands of the median arcuate ligament (MAL) and periaortic ganglionic tissue [7,8]. This anatomical condition is usually asymptomatic due to sufficient collateral blood supply but may present with functional ischemia in 10% to 24% [8,9]. While MALC was first described by Lipshutz et al more than hundred years ago [10], Harjola and Dunbar reported on the first successful surgical divisions in 1963 and 1965 respectively [11,12]

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