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All right, so this is an example of a mesenteric Doppler in a patient who had

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suspected median arcuate ligament syndrome.

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This person was having postprandial abdominal pain, and there was a concern that

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this might be going on. So you can see how this can be a challenging exam, and

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sometimes it does require a few attempts in different positions to try to elicit

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the findings. So we started with the patient

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standing upright, and we didn't have really a significant elevation in the celiac

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artery velocity. And even in exploration, we didn't really see it while standing

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up. And so we then lay the patient down, we interrogate the superior mesenteric

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artery, and then here you can see the celiac and the superior mesenteric artery

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side by side.

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And now we can start to see some changes.

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So when we go and move to the expiratory phase, you can actually start to see that

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velocity go up significantly in the proximal portion of the celiac artery.

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And even further, we can get up to almost 300 centimeters per second in expiration.

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And then you compare that to what the inspiratory looks like on supine, that's all

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the way down to 137. So that's a significant jump.

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It more than doubles to get to that point.

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So that was consistent with median arcuate ligament syndrome, with the increase of

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velocity on expiration. And just for reference, you can see what the kind of normal

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aortic velocities are, significantly less than that.

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Here's another example of median arcuate ligament syndrome, and this is a patient

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who also had a CT correlate with inspiratory and expiratory findings to sort of

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have a comparison for this. So normal aortic waveform with slightly elevated

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velocity up to 164. But as we do some other interrogation, we

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get the superior mesenteric artery in the upright imaging.

1:53

That looks fairly normal. We are in upright exploration on this with the celiac

1:58

artery, and you can see we see some modest elevations here, and then we don't see

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any significant changes with respiration with the SMA, which we would not

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necessarily expect. And then finally, we do some additional upright images with

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inspiration and then expiration of the celiac artery.

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You can see we jump essentially from 128 centimeters per second to when we do this

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on supine, we go from just a baseline of 253 or 254

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all the way to 402. So that's a pretty significant jump no matter how you slice it

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on the expiratory phase. And then the inspiratory alone here would

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be potentially enough to call a celiac stenosis.

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However, the significant change is what happens on the expiratory phase.

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When we look at the CT for comparison, you can see we have two different images

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that go along with this. These are some sagittal images, so you can look at the

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celiac artery. So here we have the SMA and then the celiac artery.

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You can see the celiac is nice and patent here on the inspiratory images.

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The top aspect of it is nice and flat.

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But then when we shift over to the expiratory images, you can see we have a

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significant change in what that looks like.

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The celiac artery all of a sudden takes sort of almost like a downturn towards the

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vessel, and then there's narrowing at the origin.

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So you can see that gets significantly tighter there.

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So that's what creates that J-shaped kind of hooked configuration of the celiac

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artery, and that was consistent with the CT findings of median arcuate ligament

3:36

syndrome.