Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients

Figure 1 Computed tomography images of orthotopic liver transplantation recipients with median arcuate syndrome in the sagittal plane. A: Patient with median arcuate ligament syndrome showing stenosis of the celiac trunk due to compression by the median arcuate ligament and the post-stenotic dilation (arrow); B: Abundant collateral circulation between the superior mesenteric artery and the celiac trunk (arrow).

Figure 2 Intraoperative photograph. A: Median arcuate ligament division; B: The hepatic artery/splenic artery patch from the donor and the right/left hepatic artery patch from the recipient were used for branch patch anastomosis with preservation of the gastroduodenal artery. MAL: Median arcuate ligament; CT: Computed tomography; HA/SA: Hepatic artery/splenic artery; RHA/LHA: Right/left hepatic artery.

Figure 3 Schematic diagram showing different types of patch anastomoses performed in this study. A: Donor: celiac trunk; recipient: hepatic/gastroduodenal artery (GDA) patch. Median arcuate ligament (MAL) was divided. Splenic artery was not ligated; B: Donor: hepatic/splenic artery (HA/SA) patch; recipient: right/left hepatic artery (RHA/LHA) patch; MAL was not divided. GDA was preserved. Splenic artery was ligated; C: Donor: common hepatic artery (CHA); recipient: RHA/LHA patch; MAL was not divided. GDA was preserved. Splenic artery was ligated; D: Donor: CHA; recipient: RHA/LHA patch; MAL was not divided. GDA was preserved. Splenic artery was not ligated; E: Donor: (1) GDA; and (2) CHA; recipient: (1) aberrant right hepatic artery; and (2) right/left hepatic artery patch; MAL was not divided. GDA was preserved. Splenic artery was not ligated; F: Donor: HA/SA patch; recipient: hepatic/GDA patch; MAL was not divided. Splenic artery was not ligated. MAL: Median arcuate ligament; CT: Computed tomography; HA/SA: Hepatic artery/splenic artery; RHA/LHA: Right/left hepatic artery; GDA: Gastroduodenal artery; SMA: Superior mesenteric artery; CHA: Common hepatic artery.