Median arcuate ligament syndrome (MALS) is a rare disorder resulting from extrinsic compression and narrowing of the celiac artery, and--less often--the superior mesenteric artery, by the relatively low insertion of the ligament and/or prominent fibrous bands or ganglionic periaortic tissue of the celiac nervous plexus. We report on a young woman who after three consecutive attempts of endovascular therapy with balloon angioplasty and stenting for MALS, each followed by gross symptom recurrence and a cumulative weight loss of 10 kg, underwent open surgical division of the ligament and reconstruction of the celiac artery. Despite the initial response of MALS to endovascular therapy, the extrinsic pressure exerted on the celiac artery by the surrounding dense fibrous/ganglionic tissue resulted in slippage of the stents and/or failure of their material. These findings militate against the use of balloon angioplasty and stenting primarily in patients with MALS without prior release of the extrinsic compression on the celiac (and/or superior mesenteric) artery by dividing the surrounding median arcuate ligament and/or ganglionic tissue with open or laparoscopic surgery.

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Spinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature.