Letters to the Editor Letters to the Editor should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ‘‘Instructions for Authors’’.) They should be no more than 3 double-spaced pages excluding an Abstract and sub-headings with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author. In general, authors of case reports should use the Letter to the Editor format. Median Arcuate Ligament Syndrome with Early Collateralization in a Liver Transplant To the Editor: A 67-year-old man with end-stage liver disease secondary to alcoholic cirrhosis underwent orthotopic liver transplantation. The initial postoperative ultrasound revealed an area of infarct in the periphery of the right lobe but otherwise good flow throughout all vessels. Subsequent ultrasounds revealed declining hepatic artery-resistive indices and a hepatic artery stenosis was visualized at the anastomosis. On postoperative Day 9, the patient returned to the operating room for an exploratory laparotomy, lysis of adhesions around the hepatic artery, and ligation of the gastroduodenal artery. Intraoperative ultrasound was performed at that time revealing improvement in hepatic artery flow. Postoperatively, the patient’s liver function continued to decline and repeat ultrasounds revealed worsening of arterial flow to the liver. A CT angiogram of the abdomen with three-dimensional reconstruction revealed stenosis of the proximal celiac artery secondary to median arcuate ligament syndrome (Fig. 1). The patient returned to the operating room for ligation of the hepatic artery and an aortohepatic bypass with bovine jump graft after attempted release of the ligament was unsuccessful. Postoperatively, the patient demonstrated good flow through the graft, but subsequently the graft thrombosed. The patient continued on a fairly routine postoperative course with elevated but stable liver function tests despite the thrombosed graft. A follow-up CT scan and ultrasound was obtained 1 month later revealing a thrombosed jump graft but with collaterals from the left hemidiaphragm (Fig. 2). The patient is now nearly 1 year out from his Address correspondence and reprint requests to Kamran Khanmoradi, M.D., Division of Transplantation, Department of Surgery, Albert Einstein Medical Center, 5401 Old York Road, Klein Building, Suite 500, Philadelphia, PA 19141. E-mail: khanmok@Einstein.edu. liver transplant and his liver continues to survive on the multiple collaterals that have formed. The median arcuate ligament is a fibrous band that is formed by the right and left diaphragmatic crura on either side of the aortic hiatus. Its normal anatomical position is at the level of the first lumbar vertebral body, superior to the origin of the celiac axis. However, in 10 to 24 per cent of the population, the ligament may be low and cross over the proximal portion of the celiac axis. The relevance of this fibrous band has been under debate since 1965 when Dunbar et al. first described a syndrome of postprandial abdominal pain and malabsorption secondary to celiac axis compression by the median arcuate ligament.1 The relevance of this ligament in liver transplantation is widely accepted because the ligament can cause a decrease in FIG. 1. CT angiogram displaying stenosis of the celiac axis secondary to median arcuate syndrome. E156 No. 9 LETTERS TO THE EDITOR E157 been recognized as a distinctively later phenomenon taking 3 months to develop mature collaterals.3 In the setting of median arcuate ligament syndrome, this delayed development of collaterals may be too late to save the graft and save the patient. We present a case of very early collateralization, which undoubtedly led to the graft and the patient’s survival. Amanda Woodworth, M.D. Kamran Khanmoradi, M.D. Radi Zaki, M.D. Stalin Campos, M.D. Mindy Horrow, M.D. Jorge Ortiz, M.D. FIG. 2. Follow-up CT scan 1 month later revealing thrombosed jump graft (thin arrow) and diaphragmatic collaterals (thick arrow). Division of Transplantation Department of Surgery Albert Einstein Medical Center Philadelphia, Pennsylvania REFERENCES celiac artery blood flow leading to hepatic artery thrombosis in liver transplant recipients.2 This is often a lethal condition and the tendency may be to retransplant these patients immediately subjecting the patient to another life-threatening surgery with an unpredictable outcome. Until recently, collateralization in the presence of hepatic artery thrombosis has 1. Dunbar JD, Molnar W, Beman F, et al. Compression of the celiac trunk and abdominal angina. AJR Am J Roentgenol 1965; 95:731–43. 2. Jurim O, Shaked A, Kiai K, et al. Celiac compression syndrome and liver transplantation. Ann Surg 1993;28:10–2. 3. Horrow MM, Blumenthal BM, Reich D, et al. Sonographic diagnosis and outcome of hepatic artery thrombosis after orthotopic liver transplantation in adults. Am J Radiol 2007;189:346–51.