45yo male for an aortogram, mesenteric angiogram +/- coeliac artery stent via R CFA +/- brachial approach. Interesting case for discussion.
- ? Mesenteric angina
- Laparoscopic median arcuate ligament release 2021 due to weight loss, nausea, chest/abdominal pain.
- Ongoing symptoms requiring admission to hospital in August – chest pain, SOB, 3 x syncopal episodes.
- Weight loss now 25kg
- Carotid dopplers, TTE, stress TTE, CTPA, CTB, troponins and ECG all negative.
- ED presentation September with same symptoms after clopidogrel loading.
- Abdominal angiography showed ongoing 90% coeliac artery stenosis
- Plan for stent in lab 4.
- Childhood asthma
- Quit smoking 2020 (20PYH)
- Depression and anxiety
- Unusual symptoms: any concerning causes not fully elucidated?
- Difficult to think of any investigation that hasn’t been done!
- Possible vagal episodes (causing syncope) due to pain
- Procedural risks?
- At initial laparoscopic ligament release, substantial bleeding risk flagged to anaesthetist.
- bleeding risk with this procedure?
- Anaesthetic technique?
- Tempting to avoid GA given history however conversion to GA in an emergency may be challenging.
- Also potential for long ++ procedure (from limited experience from the group) making light sedation challenging.
- What is median arcuate ligament syndrome? (from Uptodate)
- A.k.a. coeliac axis syndrome, coeliac artery compression syndrome, Dunbar syndrome.
- Recurrent abdominal pain related to compression of the coeliac artery by the MAL.
- Symptoms may be ischaemic or neuropathic.
- Triad: post-prandial abdominal pain, weight loss, abdominal bruit.
- 30yo+, 4 x more common in women
- Careful patient selection for intervention needed, as may be an incidental finding in asymptomatic people, or not clearly related to symptoms due to another cause.
- Treated initially with a laparoscopic ligament release. Second line treatments include ganglionectomy, percutaneous revascularisation or surgical revascularisation.
- Procedural anaesthetist notified -> will discuss bleeding risks with surgeon on the day and have blood available in lab 4 if thought prudent (nil previous Abs)
- GA thought to be safe and appropriate
- Nil further Investiagtions