Is Coeliac Revascularisation Still Required after Median Arcuate Ligament Release? Two Decades of Institutional Experience and Changing Trends.

Abstract

This study aimed to evaluate the role and clinical outcomes of coeliac artery (CA) revascularisation in patients undergoing median arcuate ligament release (MALR) for median arcuate ligament syndrome (MALS). Patients who underwent MALR between 2001 and 2024 were reviewed retrospectively. Those who underwent CA revascularisation were analysed. Variables included symptoms, imaging, operation findings, and outcomes. Propensity score matching (PSM) with 1:1 nearest neighbour matching was performed using prespecified covariables. Among the 274 patients who underwent MALR, 34 patients underwent CA revascularisation either concurrently or as a delayed intervention. The median age was 43 years (interquartile range [IQR] 36, 50), and 25 of 34 patients (73.5%) were women. Revascularisation was performed concurrently with MALR in 26 patients (76.5%), including 17 aortocoeliac bypasses and nine patch angioplasties. Positive pain response was reported in 21 of 26 patients (80.8%) and positive nausea response in 22 of 26 patients (85.7%). PSM identified 33 matched pairs of patients with and without CA revascularisation. Baseline covariables were well balanced (standardised mean differences < 0.1). Symptom response rates were similar between groups, with positive pain response reported in 24 of 33 patients (72.7%) in the revascularisation group and 26 of 33 patients (78.8%) in the non-revascularisation group (p = .57). Similarly, among patients who reported nausea, a positive response was observed in 22 of 25 patients (88.0%) and 19 of 21 patients (90.5%), respectively (p = .79). In this large single institution cohort, coeliac revascularisation after MALR declined substantially over time, with comparable symptom outcomes to MALR alone. These findings suggest that, for most patients, MALR alone is appropriate, with revascularisation reserved for highly selected cases.