Compression of the left renal artery and celiac trunk by diaphragmatic crura
2009; Elsevier BV; Volume: 50; Issue: 4 Linguagem: Inglês
10.1016/j.jvs.2009.05.004
ISSN1097-6809
AutoresG. Gaebel, Irene Hinterseher, H. D. Saeger, Hendrik Bergert,
Tópico(s)Vascular anomalies and interventions
ResumoSymptomatic compression of the celiac trunk by crura of the diaphragm is a rare disorder. Even more infrequent external compression of renal arteries is found. Although the indication for surgical therapy is controversially discussed in the literature for celiac artery compression syndrome, it is unequivocally for renal artery entrapment. We present the case of a young woman who was assigned to our hospital with arterial hypertension and stenosis of the left renal artery. After percutaneous transluminal angioplasty was performed, immediate recoil occurred. Therefore, the suspicion of entrapment by diaphragmatic crura was expressed. Additionally performed diagnostic procedures including computed tomography (CT)-angiography verified our suspicion. Surgical decompression of both vessels was successfully performed. Symptomatic compression of the celiac trunk by crura of the diaphragm is a rare disorder. Even more infrequent external compression of renal arteries is found. Although the indication for surgical therapy is controversially discussed in the literature for celiac artery compression syndrome, it is unequivocally for renal artery entrapment. We present the case of a young woman who was assigned to our hospital with arterial hypertension and stenosis of the left renal artery. After percutaneous transluminal angioplasty was performed, immediate recoil occurred. Therefore, the suspicion of entrapment by diaphragmatic crura was expressed. Additionally performed diagnostic procedures including computed tomography (CT)-angiography verified our suspicion. Surgical decompression of both vessels was successfully performed. The celiac artery compression syndrome (CACS) is a disorder caused by extrinsic compression that the relatively inferior insertion of the median arcuate ligament (MAL) or prominent fibrous bands and ganglionic periaortic tissue of the celiac nervous plexus may exert on the celiac artery. It is a frequent finding in imaging studies performed for screening or diagnosis. Most of these patients have no symptoms related to celiac artery compression. But few patients present with a variety of symptoms.1Gloviczki P. Duncan A.A. Treatment of celiac artery compression syndrome: does it really exist?.Perspect Vasc Surg Endovasc Ther. 2007; 19: 259-263Crossref PubMed Scopus (60) Google Scholar Intermittent foregut ischemia and weight loss are the most frequently described symptoms.2Harjola P.T. A rare obstruction of the coeliac artery Report of a case.Ann Chir Gynaecol Fenn. 1963; 52: 547-550PubMed Google Scholar Occasionally, in addition to the celiac trunk, the constricting effects may also be exerted on the superior mesenteric artery and the renal arteries. These findings are even more infrequent and only a few cases have been reported in literature.3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar, 4Bacourt F. Depondt J.L. Lacombe P. Mignon E. [Compression of the left renal artery by the diaphragm].[Article in French] J Mal Vasc. 1992; 17: 315-318PubMed Google Scholar, 5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar, 6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar In cases of renal artery entrapment by the MAL, the patients usually present with hypertension.5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar, 7Baguet J.P. Thony F. Tremel F. Cracowski J.L. Sessa C. Mallion J.M. [Compression of the renal artery by a musculo-tendinous band: an unrecognised cause of renovascular hypertension].[Article in French] Arch Mal Coeur Vaiss. 1999; 92: 1767-1772PubMed Google Scholar Here we introduce a patient with entrapment of the left renal artery (LRA) and the celiac trunk by surrounding dense fibrous and ganglionic tissue originating from the diaphragmatic crura, who had to undergo open surgical decompression of both vessels. A 19-year-old woman with an unremarkable medical history presented with recurring tachycardia and hypertension (systolic pressure 200 mm Hg). Her general practitioner administered a low-dose beta-blocker therapy with limited success. The performed cardiac diagnostics were inconspicuous. For further diagnosis, a magnetic resonance imaging (MRI) scan was performed. A short ostial stenosis of the LRA was detected in the MRI scan. With the suspect of a fibromuscular dysplasia, the patient was referred to our clinic. A duplex ultrasound scan determined a severe ostial stenosis of the LRA with a peak systolic velocity (PSV) of 4.5 m/s (renal to aortic velocity ratio: 4.1; approximately 75%) with no variation in inspiration and expiration. Initially, the other visceral arteries and the right renal artery were described as normal. In accordance with these findings, stenting of the renal stenosis was planned. In the angiography, a high origin of the LRA from the aorta was seen just beneath the origin of the celiac trunk. During the same session, the patient underwent a percutaneous transluminal angioplasty (PTA). However, immediate recoil occurred. Intervention was abandoned and further diagnostic procedures were initiated. We performed a computed tomography (CT) scan, which depicted an entrapment of the LRA by bands originating from the left crura of the diaphragm (Fig 1). Additionally, the root of the celiac trunk was compressed and narrowed by the median arcuate ligament (Fig 2). Because we did not have access to the earlier external MRI pictures, we performed a magnetic resonance angiography (MRA) scan in inspiration and expiration. During inspiration, a severe stenosis of the celiac trunk was depicted which decreased in expiration (Fig 3). The LRA stenosis was high-grade and independent of respiratory action. Repeated duplex ultrasound scans of the celiac trunk revealed a PSV of 3.2 m/s in inspiration and 2.1 m/s in expiration. Therefore, we indicated a need for surgical therapy.Fig 2The celiac trunk course inferiorly from its origin, the proximal portions pulled down an in toward the aorta, causing severe narrowing (>80%; big arrow) by the median arcuate ligament (small arrows) well demonstrated in the sagittal computed tomography (CT) slices.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Magnetic resonance angiography performed in expiration discloses a mild ostial stenosis of the celiac artery. But, performed during inspiration, a high-grade stenosis is depicted (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The abdomen was entered via a transverse epigastric incision. The left lobe of the liver was mobilized to expose the aorta. After the bursa omentalis had been opened and the gastric curvature had been reflected, cranially the suprarenal aorta was explored. During the operation we found an exceptional wide caliber of the superior mesenteric artery (SMA). We interpreted this as a sign for an increased collateral circulation from the SMA. Above the SMA we dissected pre-aortal and left side of the aorta dense fibrous and ganglionic tissue. The root of the LRA was surrounded by hypertrophic partially scarred fibers of the diaphragm. After we resected those fibers, the lumen of the LRA increased immediately (Fig 4). Afterwards, we subtly explored the celiac trunk which was also compressed and showed a narrowed lumen. After resection of those dense fibrous structures, an immediate decompression of the celiac trunk was observed. An intraoperative Doppler ultrasound scan did not show any residual stenosis of the LRA and all mesenteric arteries. In the histologic analysis of the resected tissue, ganglionic and muscular structures were seen. A postoperative Duplex ultrasound scan was repeated and revealed normal flow in both renal and all visceral arteries during inspiration (PSV aorta: 1.4 m/s; LRA: 1.4 m/s; and celiac trunk: 2.4 m/s). Bisoprolol was withdrawn postoperatively and the blood pressure remained in range between values of 125/75 mm Hg and 145/80 mm Hg. The renal function was not altered (creatinine preoperative 55 μmol/L and postoperative 53 μmol/L). The patient was discharged without any complications on postoperative day 8. Doppler ultrasound scan and clinical follow-up at 6, 12, and 18 months after surgery confirmed the normalization of renal blood flow without restenosis (resistance index: LRA 0.61; right renal artery [RRA] 0.62; and superior mesenteric artery [SMA] 0.89). At these time points, the patient was doing well without any clinical findings. Renal artery stenosis accounts for about 1% of patients with hypertension, but its incidence rises to 30% in cases of refractory hypertension.8Safian R.D. Textor S.C. Renal-artery stenosis.N Engl J Med. 2001; 344: 431-442Crossref PubMed Scopus (861) Google Scholar The two major causes are atherosclerosis and fibromuscular dysplasia. Extrinsic compression of the renal artery is a very rare cause of hypertension. Congenital abnormalities, such as abnormal musculo-tendinous fibers,3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar, 9d'Abreu Strickland B. Developmental renal-artery stenosis.Lancet. 1962; 2: 517-521Abstract PubMed Scopus (19) Google Scholar, 10Silver D. Clements J.B. Renovascular hypertension from renal artery compression by congenital bands.Ann Surg. 1976; 183: 161-166Crossref PubMed Scopus (14) Google Scholar high ectopic renal artery origin,10Silver D. Clements J.B. Renovascular hypertension from renal artery compression by congenital bands.Ann Surg. 1976; 183: 161-166Crossref PubMed Scopus (14) Google Scholar, 11Dure-Smith P. Bloch R.D. Fymat A.L. Chang P. Hammond P.G. Renal artery entrapment by the diaphragmatic crus revealed by helical CT angiography.AJR Am J Roentgenol. 1998; 170: 1291-1292Crossref PubMed Scopus (12) Google Scholar or hypertrophic diaphragmatic crus12Martin Jr, D.C. Anomaly of the right crus of the diaphragm involving the right renal artery.Am J Surg. 1971; 121: 351-354Abstract Full Text PDF PubMed Scopus (4) Google Scholar were found to be responsible for these entrapments. The median arcuate ligament is a condensation of the medial fibrous borders of the two crura of the diaphragm as they decussate to form the ventral border of the aortic hiatus. The ligament is highly variable, with its appearance ranging from a well-defined ligamentous mass to an amorphous area of connective tissue.13Lindner H.H. Kemprud E. A clinicoanatomical study of the arcuate ligament of the diaphragm.Arch Surg. 1971; 103: 600-605Crossref PubMed Scopus (138) Google Scholar A relatively inferior insertion of the median arcuate ligament and prominent fibrous bands, or the ganglionic periaortic tissue of the celiac nervous plexus, could be the cause of the extrinsic compression on the celiac trunk.6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar, 14Reilly L.M. Ammar A.D. Stoney R.J. Ehrenfeld W.K. Late results following operative repair for celiac artery compression syndrome.J Vasc Surg. 1985; 2: 79-91PubMed Scopus (178) Google Scholar Renal artery entrapment usually develops in a renal artery with its origin high on the aorta, as observed in the presented case where the origin of the LRA was just underneath the origin of the celiac trunk. The mechanism evoked is an anomaly of migration of the kidneys, which seems to be more common on the left side. The diaphragmatic fibers cause a verticalization of the root of the renal artery and lead to a stenosis.15Thony F. Baguet J.P. Rodiere M. Sessa C. Janbon B. Ferretti G. Renal artery entrapment by the diaphragmatic crus.Eur Radiol. 2005; 15: 1841-1849Crossref PubMed Scopus (26) Google Scholar, 16Clément C. Ruiz R. Costa-Foru B. Nicaise H. Extrinsic compression of the renal artery by diaphragmatic crus.Ann Vasc Surg. 1990; 4: 305-308Abstract Full Text PDF PubMed Scopus (11) Google Scholar Since the first report by d'Abreu and Strickland,9d'Abreu Strickland B. Developmental renal-artery stenosis.Lancet. 1962; 2: 517-521Abstract PubMed Scopus (19) Google Scholar only a few cases of renal artery entrapments have been reported in the literature.3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar, 4Bacourt F. Depondt J.L. Lacombe P. Mignon E. [Compression of the left renal artery by the diaphragm].[Article in French] J Mal Vasc. 1992; 17: 315-318PubMed Google Scholar, 10Silver D. Clements J.B. Renovascular hypertension from renal artery compression by congenital bands.Ann Surg. 1976; 183: 161-166Crossref PubMed Scopus (14) Google Scholar, 11Dure-Smith P. Bloch R.D. Fymat A.L. Chang P. Hammond P.G. Renal artery entrapment by the diaphragmatic crus revealed by helical CT angiography.AJR Am J Roentgenol. 1998; 170: 1291-1292Crossref PubMed Scopus (12) Google Scholar, 12Martin Jr, D.C. Anomaly of the right crus of the diaphragm involving the right renal artery.Am J Surg. 1971; 121: 351-354Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 16Clément C. Ruiz R. Costa-Foru B. Nicaise H. Extrinsic compression of the renal artery by diaphragmatic crus.Ann Vasc Surg. 1990; 4: 305-308Abstract Full Text PDF PubMed Scopus (11) Google Scholar, 17Spies J.B. LeQuire M.H. Robison J.G. Beckett Jr, W.C. Perkinson D.T. Vicks S.L. Renovascular hypertension caused by compression of the renal artery by the diaphragmatic crus.AJR Am J Roentgenol. 1987; 149: 1195-1196Crossref PubMed Scopus (9) Google Scholar, 18Villanueva A. Nuñez R.V. Baltar L. Ruibal G. Arterial hypertension and extrinsic renal artery compression: case report.J Cardiovasc Surg (Torino). 1972; 13: 617-619PubMed Google Scholar, 19Baguet J.P. Thony F. Sessa C. Mallion J.M. Stenting of a renal artery compressed by the diaphragm.J Hum Hypertens. 2003; 17: 213-214Crossref PubMed Scopus (29) Google Scholar Indeed these fibrous bands originating from the diaphragm are more commonly known for the celiac artery compression syndrome, also known as median arcuate ligament syndrome. It has proven to be controversial in definition and relevance. Asymptomatic extrinsic compression of the celiac artery is quite common; it has been confirmed with direct pressure measurements in 3% to 10% of patients who undergo orthotopic liver transplantation. Patients with symptomatic CACS may present in a variety of ways. Most have symptoms of chronic mesenteric ischemia and present with weight loss, postprandial abdominal pain, nausea and vomiting, or diarrhea. The diagnosis continues to be controversial, because in most patients the SMA is not affected. It has been implicated that the CACS may cause an increased collateral circulation from the SMA.1Gloviczki P. Duncan A.A. Treatment of celiac artery compression syndrome: does it really exist?.Perspect Vasc Surg Endovasc Ther. 2007; 19: 259-263Crossref PubMed Scopus (60) Google Scholar In the presented case, the patient did not show any familiar symptoms of CACS, but during the operation a wide caliber of the SMA was observed, which would confirm these implications. Combined entrapment of visceral and renal arteries has rarely been described.3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar, 4Bacourt F. Depondt J.L. Lacombe P. Mignon E. [Compression of the left renal artery by the diaphragm].[Article in French] J Mal Vasc. 1992; 17: 315-318PubMed Google Scholar, 5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar, 6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar Interestingly, in every case reported, the patient presented with hypertension. In only one case, postprandial epigastric pain was described.6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar In most of the patients, the diagnosis was initially missed and interventional or operative procedures were performed that failed. Therefore, the diagnosis of MAL compression plays a decisive role. A Doppler ultrasound scan allows the visualization of renal blood flow during a complete respiratory cycle. Indeed, during the same procedure, it permits detection of stenosis, presence of flow demodulation, and increase of flow velocities during expiration. But in cases of severe entrapment, the changes of flow velocities during the respiratory cycle can decrease or even dissolve,20Ilica A.T. Kocaoglu M. Bilici A. Ors F. Bukte Y. Senol A. et al.Median arcuate ligament syndrome: multidetector computed tomography findings.J Comput Assist Tomogr. 2007; 31: 728-731PubMed Google Scholar as experienced for the LRA in our patient. Also, an ultrasound scan is an accurate examination for screening renal artery stenoses, but it does not allow the analysis of the relationship between renal artery and muscular structures. Conventional arteriography has the same disadvantage. CT and MRI scans allow for depiction of these compressions. However, reports of visceral and renal artery entrapment with these imaging tools are few.6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar, 11Dure-Smith P. Bloch R.D. Fymat A.L. Chang P. Hammond P.G. Renal artery entrapment by the diaphragmatic crus revealed by helical CT angiography.AJR Am J Roentgenol. 1998; 170: 1291-1292Crossref PubMed Scopus (12) Google Scholar, 15Thony F. Baguet J.P. Rodiere M. Sessa C. Janbon B. Ferretti G. Renal artery entrapment by the diaphragmatic crus.Eur Radiol. 2005; 15: 1841-1849Crossref PubMed Scopus (26) Google Scholar A great advantage of the CT scan, compared to the MRI scan, is the visualization of artherosclerotic lesions. If there are clinical and sonographic findings suggesting entrapment by the MAL, these findings should be corroborated by a CT angiography scan.6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar, 11Dure-Smith P. Bloch R.D. Fymat A.L. Chang P. Hammond P.G. Renal artery entrapment by the diaphragmatic crus revealed by helical CT angiography.AJR Am J Roentgenol. 1998; 170: 1291-1292Crossref PubMed Scopus (12) Google Scholar It permits visualization of the diaphragm and its relationships with the aorta and its branches. Furthermore, thin fibrous bands from the diaphragm insertion are well demonstrated by CT scan. In 1995, the first diagnosis of renal artery stenosis with a CT scan was reported by Kopecky et al,6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar since then it is considered the “gold standard” tool for diagnosing this pathology. Ilica et al20Ilica A.T. Kocaoglu M. Bilici A. Ors F. Bukte Y. Senol A. et al.Median arcuate ligament syndrome: multidetector computed tomography findings.J Comput Assist Tomogr. 2007; 31: 728-731PubMed Google Scholar recently described nicely the CT scan findings suggesting MAL compression. For the celiac trunk and SMA narrowing, kinking, and inferior displacement on sagittal views are indicative. Coursing inferior and medial of narrowed proximal renal artery adjacent to the aorta suggests MAL compression on frontal reformations. These findings can distinguish this entity from artherosclerotic stenosis. Treatment for CACS has historically involved surgical release of the celiac trunk from extrinsic compression by the MAL or division of fibrotic celiac ganglia. Mihas et al21Mihas A.A. Laws H.L. Jander H.P. Surgical treatment of the celiac axis compression syndrome.Am J Surg. 1977; 133: 688-691Abstract Full Text PDF PubMed Scopus (30) Google Scholar reported 6 patients with CACS with 4 undergoing surgical reconstruction without benefit for painful symptoms lasting greater than 20 months. Although angioplasty and stenting of visceral arteries seems to be successful in the setting of atherosclerosis, their use in the setting of CACS has been questioned because of the presence of extrinsic compression.17Spies J.B. LeQuire M.H. Robison J.G. Beckett Jr, W.C. Perkinson D.T. Vicks S.L. Renovascular hypertension caused by compression of the renal artery by the diaphragmatic crus.AJR Am J Roentgenol. 1987; 149: 1195-1196Crossref PubMed Scopus (9) Google Scholar, 22Jaik N.P. Stawicki S.P. Weger N.S. Lukaszczyk J.J. Celiac artery compression syndrome: successful utilization of robotic-assisted laparoscopic approach.J Gastrointestin Liver Dis. 2007; 16: 93-96PubMed Google Scholar The increasing applicability of stent deployment for mesenteric occlusive disease has given interventional radiologists the opportunity to expand the use of PTA and stenting to patients with CACS before primary surgical intervention. However, the few attempts of angioplasty and stenting patients with entrapment of renal arteries by diaphragmatic crura are not convincing.5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar, 15Thony F. Baguet J.P. Rodiere M. Sessa C. Janbon B. Ferretti G. Renal artery entrapment by the diaphragmatic crus.Eur Radiol. 2005; 15: 1841-1849Crossref PubMed Scopus (26) Google Scholar, 19Baguet J.P. Thony F. Sessa C. Mallion J.M. Stenting of a renal artery compressed by the diaphragm.J Hum Hypertens. 2003; 17: 213-214Crossref PubMed Scopus (29) Google Scholar In the case presented here, renal angioplasty failed and immediate recoil occurred. A review of the literature revealed only 4 patients where renal artery entrapment was treated through stenting.5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar, 15Thony F. Baguet J.P. Rodiere M. Sessa C. Janbon B. Ferretti G. Renal artery entrapment by the diaphragmatic crus.Eur Radiol. 2005; 15: 1841-1849Crossref PubMed Scopus (26) Google Scholar This treatment failed in 2 patients because the stent was compressed during respiratory motions and this led to stent rupture. The other patients treated with balloon-expandable stents did not collapse and remained patent on CT scan follow-up controls at 6 months. But the patients did not show any significant decrease in their blood pressure level or improvement of their impaired renal function.15Thony F. Baguet J.P. Rodiere M. Sessa C. Janbon B. Ferretti G. Renal artery entrapment by the diaphragmatic crus.Eur Radiol. 2005; 15: 1841-1849Crossref PubMed Scopus (26) Google Scholar Perhaps the potential benefits of the developing stent fabrication could have significant implications in mechanical fatigue. With current standards, primary stent deployment should be avoided in the likely occurrence of extrinsic compression or motion. We therefore indicated and successfully performed open surgery to release both vessels. All patients reported in the literature eventually were treated successfully by open surgery (Table). In every patient, the extensive dissection and resection of the musculotendinous bands surrounding the compressed vessels was performed, even though the patients were asymptomatic regarding the compression of the visceral arteries.3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar, 4Bacourt F. Depondt J.L. Lacombe P. Mignon E. [Compression of the left renal artery by the diaphragm].[Article in French] J Mal Vasc. 1992; 17: 315-318PubMed Google Scholar, 5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar The intention for us to perform an extended resection of the hypertrophic diaphragmatic crura with release of the celiac trunk without symptomatic CACS was the easy feasibility and the possibility that a symptomatic complication can occur in the future.TableOverview of described cases with multivessel entrapmentAuthorAgeGenderCompressed arteriesTreatmentFollow-upVahdat et al3Vahdat O. Creemers E. Limet R. [Stenosis of the right renal artery caused by the crura of the diaphragm. Report of a case].[Article in French] J Mal Vasc. 1991; 16: 304-307PubMed Google Scholar23♀SMARRA(1) Angioplasty failed(2) Double revascularization with venous graft – early thrombosis in both grafts(3) Resection of MAL6 monthsBacourt et al4Bacourt F. Depondt J.L. Lacombe P. Mignon E. [Compression of the left renal artery by the diaphragm].[Article in French] J Mal Vasc. 1992; 17: 315-318PubMed Google Scholar21♂CALRAResection of MAL4 yearsKopecky et al6Kopecky K.K. Stine S.B. Dalsing M.C. Gottlieb K. Median arcuate ligament syndrome with multivessel involvement: diagnosis with spiral CT angiography.Abdom Imaging. 1997; 22: 318-320Crossref PubMed Scopus (61) Google Scholar50♀CASMARRALRAResection of MAL and patchplasty of CA6 monthsDeglise et al5Déglise S. Corpataux J.M. Haller C. Binaghi S. Meuwly J.Y. Qanadli S.D. Bilateral renal artery entrapment by diaphragmatic crura: a rare cause of renovascular hypertension with a specific management.J Comput Assist Tomogr. 2007; 31: 481-484Crossref PubMed Scopus (11) Google Scholar39♂SMARRALRA(1) Angioplasty with balloon expandable stent (LRA) – stent rupture after 6 months(2) Resection of MAL, reinsertion of RRA and rVSM bypass to LRA6 monthsCA, Celiac artery; SMA, superior mesenteric artery; RRA, right renal artery; LRA, left renal artery; MAL, median arcuate ligament; rVSM, reversed vena saphena magna. Open table in a new tab CA, Celiac artery; SMA, superior mesenteric artery; RRA, right renal artery; LRA, left renal artery; MAL, median arcuate ligament; rVSM, reversed vena saphena magna. Combined renal artery and celiac trunk external compression by fibrous bands from the diaphragm is an extremely rare finding. Like external compression of the celiac trunk, it was demonstrated that renal artery external compression does not benefit from angioplasty or stenting because of elastic recoil or stent fracture. Therefore, primary angioplasty and stenting are not indicated for this entity. In our opinion, today the procedure of first choice is surgical decompression of the vessels by dividing or resecting the surrounding dense fibrous and ganglionic tissue. After surgery, long-term duplex ultrasound scan and clinical follow-up is necessary for these patients.
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