The authors seek to understand the etiology of celiac artery compression syndrome (CACS). Specifically, they try to provide an answer to the question of why there are such extremes of clinical symptoms in patients with similar degrees of celiac artery compression. Although previous authors have hypothesized that the celiac ganglion may play a larger role, van Petersen et al believe that the degree of mesenteric artery collateralization is the root of these differences. By carefully categorizing the collateral artery into three groups by the degree of collaterals, the authors demonstrate that if there are more collaterals already present at the time of median arcuate ligament release (ie, grade 2 collaterals), the less likely the patient will improve with open or laparoscopic intervention. These data strongly support the role of ischemic pathophysiology of CACS, which has been debated fiercely in the past. In one of the landmark studies of surgical treatment of CACS, Reilly et al1Reilly L.M. Ammar A.D. Stoney R.J. Ehrenfeld W.K. Late results following operative repair for celiac artery compression syndrome.J Vasc Surg. 1985; 2: 79-91Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar noted that 70% of patients whose symptoms resolved had a patent celiac artery, whereas 75% of patients with ongoing symptoms had a stenotic or occluded celiac artery. These data led many to wonder what mechanism allowed 30% of the asymptomatic patients with a stenotic or occluded celiac artery to remain asymptomatic. The answer may be collateral blood flow, as now demonstrated in this report. Unfortunately, the use of a diagnostic angiogram for every patient preoperatively may be cumbersome in clinical practice where computed tomography angiogram is the norm. If identification and grading of mesenteric collaterals could be defined by computed tomography, the clinical relevance of their study would increase. Ideally, imaging could be done with magnetic resonance imaging or duplex ultrasound in this young population where radiation should be limited. At present, it is not clear whether the presence of grade 2 collaterals preoperatively should be a contraindication to median arcuate ligament release, but the authors advise a prospective review. Because of the small case numbers of CACS, this important future work seems ideally suited for a multicenter prospective registry. Clinical significance of mesenteric arterial collateral circulation in patients with celiac artery compression syndromeJournal of Vascular SurgeryVol. 65Issue 5PreviewAlthough extensive collateral arterial circulation will prevent ischemia in most patients with stenosis of a single mesenteric artery, mesenteric ischemia may occur in these patients, for example, in patients with celiac artery compression syndrome (CACS). Variation in the extent of collateral circulation may explain the difference in clinical symptoms and variability in response to therapy; however, evidence is lacking. The objective of the study was to classify the presence of mesenteric arterial collateral circulation in patients with CACS and to evaluate the relation with clinical improvement after treatment. Full-Text PDF Open Archive