What Is the Median Arcuate Ligament?
The median arcuate ligament is a normal anatomical structure that forms the superior margin of the aortic hiatus in the diaphragm. In most people it sits well above the celiac artery takeoff. In patients with MALS, the ligament sits lower than normal, hooking over the celiac artery and compressing it — particularly during exhalation when the diaphragm descends.
MALS Symptoms
The classic MALS triad consists of post-prandial (after-eating) abdominal pain, significant unintentional weight loss (because patients avoid eating to prevent pain), and an audible abdominal bruit — a whooshing sound caused by turbulent flow through the compressed celiac artery. Symptoms are typically located in the epigastric region (upper-middle abdomen) and are often described as cramping, pressure, or a sharp ache that peaks 15–45 minutes after meals and subsides within one to two hours.
MALS Diagnosis
MALS is frequently misdiagnosed as irritable bowel syndrome, gastroparesis, or functional abdominal pain because the symptoms are nonspecific. Diagnosis requires a combination of clinical suspicion and targeted imaging. Duplex ultrasound can detect the characteristic elevated peak velocities in the celiac artery. CT angiography or MRI angiography provides anatomical detail and shows the “J-shaped” hook deformity of the compressed celiac artery. Catheter angiography performed in inspiration and expiration confirms dynamic compression.
MALS Treatment: Mesenteric Revascularization
Treatment of MALS involves surgical release of the median arcuate ligament — dividing the fibrous bands compressing the celiac artery — combined with celiac plexus ganglionectomy to address the neural component of the pain. Laparoscopic (minimally invasive) division is increasingly performed, offering faster recovery than open surgery. After ligament release, if the celiac artery remains narrowed due to post-stenotic changes, mesenteric revascularization — endovascular stenting or surgical reconstruction of the celiac artery — is performed to restore normal flow.
TOS Treatment: Arterial & Venous TOS Decompression
Vascular TOS (both arterial and venous) requires surgical decompression of the thoracic outlet, typically via first rib resection through a transaxillary or supraclavicular approach. Removing the first rib and releasing any fibromuscular bands relieves compression and eliminates the mechanical cause of the disease. Venous TOS may require additional venous stenting or venoplasty after decompression. Arterial TOS may require repair of arterial aneurysm or bypass of a diseased subclavian artery.