Median arcuate ligament syndrome (MALS) is an anatomic disorder causing external arterial compression by an inferiorly inserted median arcuate ligament (MAL) or dense fibrous bands. It is CT-graphically present in up to 24% of the population with only <1% reporting symptoms (e.g. angor abdominalis). Mostly the celiac artery is affected in MALS. Limited cases of renal artery compression by diaphragmatic crura have been described; especially cases of compression of both the celiac trunk and a renal artery by diaphragmatic fibrous bands are very rare.

We report a case of MALS with both compression of the celiac trunk and the left renal artery by diaphragmatic crura in a 35-year-old male patient who admitted in a peripheral center.

A 35-year-old male patient was treated for hypertension for five years but at the moment of admission, proved to be more difficult to manage. Upon onset of medical treatment, a renal artery stenosis had been detected. However, because of initial successful medical treatment no intervention was deemed necessary. New CT angiography showed a high-grade stenosis of the left renal artery as well as of the celiac trunk with a progressive aneurysm at the dorsal border of the proximal superior mesenteric artery (SMA). Both stenoses seemed associated with the diaphragmatic crura. After careful discussion with the nephrologist, the interventional radiologist and the patient, a surgical treatment was proposed with a dual purpose: solving the renovascular hypertension and preventing further dilatation of the aneurysm at the dorsal border of the proximal SMA. Through median laparotomy the diagnosis was confirmed, dense fibrous bands originating from the diaphragm were removed releasing both left renal artery and celiac trunk. Postoperative course was uneventful. At 3-month follow-up antihypertensive medication could be reduced and control CT abdomen showed no growth of the SMA aneurysm.

External arterial compression of a renal artery by diaphragmatic crura can be an atypical cause of renal stenosis in patients with otherwise healthy arteries. This can result in therapy resistant hypertension. It is important to include external arterial compression by diaphragmatic crura in the diagnostic landscape in these patients, as isolated endovascular treatment in these cases has proven to offer bad outcomes. Surgical decompression is the required treatment, this can be performed laparoscopically or through open approach. The open approach is preferred when there is a possible need for vessel reconstruction. Very rarely, a combined entrapment of a renal artery and the celiac trunk can be seen. As there is limited data, treatment should always be tailored to the patient.