My name is Lori Lizansky. I'm the chairperson for the SBU eLearning Educational Committee. Before we begin, I have a couple of notes from the SBU office to share with any first-time attendees. The webinar will be recorded and available online after tonight for attendees through the SBU website at no charge. Please take a moment to familiarize yourself with the GoToWebinar program. Everybody should see a questions section along the side menu of your screen on the right-hand side. It's near the bottom of the column just above Chat. That's where you can type in any questions that come to mind during the presentation. And at the end of tonight's talk, we should have some time for discussion. Now, to receive your CME from tonight's lecture, you need to wait for an email from the SBU office containing an evaluation. You should get that email in about a week. Once you get the email, complete the evaluation, and then your CME certificate will just automatically pop up. Tonight, we're honored to have Marybeth Georges speaking this evening on the subject of median arcuate ligament compression syndrome. Marybeth is a board-certified vascular technologist who has been on staff at University of Chicago for the last 16 years. Marybeth earned her degree from Rush University in Chicago, and she now serves as a clinical instructor at U of C, mentoring students from the very same vascular sonography program where she earned her degree. So full-circle moment. Marybeth has held board positions for Chicago Area Vascular Association, and she's an active member of SBU, where she's given multiple presentations and general session and workshops. Marybeth has also been a contributor to textbooks published by Inside Ultrasound, such as Vascular Reference Guide and the Venus Vascular Reference Guide. Marybeth performs a wide range of vascular studies in her daily work, but is especially interested in mesenteric disease, which is the topic she will be presenting for us tonight. So now, if you would, please join me in welcoming Marybeth Georges. Hi, everybody. Thank you for joining me tonight. I hope you can all hear me. I've been having some technical difficulties, but I'm here to talk to you tonight about medial narcotic ligament compression syndrome. As Lori said, I've been at the University of Chicago for the past 16 years. So we do quite a few of these exams there, so I'd like to go over a few things with you guys. I have no disclosures. The overview of this presentation will go over a good understanding of male symptoms, how to perform male's duplex, and then general knowledge of diagnostic criteria. So, Median Arculate Ligament Compression Syndrome is referred to as MALS. It's often referred to as Celiac Artery Compression Syndrome, Celiac Axis Syndrome, or Dunbar Syndrome. Syndromes are often difficult to diagnose. As a group of symptoms, they consistently occur together, but can often be part of many different diagnoses. It is important to note that Median Arculate Ligament Compression of the Celiac Artery is different than having Median Arculate Ligament Compression Syndrome. The syndrome is the physical response and symptoms the patient experiences. A patient may have compression of the celiac artery, but not necessarily experience any physical response. Therefore, they don't have MALS, they have compression of the celiac artery. So, the definition of MALS is when the celiac axis is being compressed by the Median Arculate Ligament and the patient has symptoms. It is most often found in pediatric females more than males. So, what are the symptoms that patients mostly have? Usually, we hear this pain after eating, pain after exercise, bloating, vomiting, diarrhea, nausea. They develop a fear of food and generally have about a 20-pound weight loss. It's mostly pain in the upper middle stomach area. But the biggest thing that people often hear is this fear of food. They're afraid to eat, and it's produced from the lack of blood supply to the gut. So, why is there pain after eating? The celiac artery supplies blood flow to the digestive system, specifically the stomach and the liver, hence why patients have pain after eating. The blood flow to the stomach is restricted, making digestion very painful. So, it's essentially claudication for the stomach. The Median Arculate Ligament is the fibrous band of the diaphragm that attaches the right and left crura. It is shaped like an arch, and it connects the diaphragm to the spine. Surrounding tissue includes the celiac plexus nerves. And the celiac artery is also known as the celiac axis and the celiac trunk. As you can see here in this picture, you can see the anatomy of the celiac artery coming off first and the SMA below it. So, what do the abdominal vessels supply specifically? The celiac artery supplies the foregut. The hepatic artery supplies the liver. The splenic artery supplies the spleen, as well as portions of the pancreas and stomach. And the SMA supplies the foregut and the second part of the duodenum. And the IMA supplies the hindgut and large intestines. There's many common differential diagnoses that we hear associated with males. Given the number of symptoms that patients may have, it's no wonder that they have so many different diagnoses. The most common ones we hear of are GERD, anorexia, or bulimia. POTS, appendicitis, gallstones, gastritis, IBS, Crohn's, or ulcers. So, how do we evaluate for males with duplex ultrasound? So, the methods we use, the patient should be MPO for the exam and fasting for at least eight hours. Perform the exam in the morning to eliminate bowel gas shadowing. Have the patient lay flat on their back, hand on their lap, or on their lap. If the patient is on the floor, they should be on the floor. Have the patient lay flat on their back, hand to their side, or behind their head. I don't recommend behind their head. However, if that's the way you'll get all your images, then that's the way you'll have them lay. Use a low-frequency probe, two to four megahertz typically. Obtain all your resting velocities necessary. Explain deep inspiration method to the patient and make sure that they really understand this. And then assess the ciliac artery with deep inspiration. The duplex protocol measures the peak and end-diastolic velocity with color and Doppler of the supraciliac aorta, the ciliac artery at the origin, proximal and distal, and now that is at rest and with deep inspiration, the hepatic artery and the splenic artery at rest, the origin, proximal, mid, and distal segments of the SMA, as well as the origin of the IMA. You always want to try to obtain B-mode images when possible. I realize this isn't always possible, but it's best if you can at least show nice, clear lumens. So B-modes of the supraciliac aorta, the ciliac artery in long or in trans, the hepatic artery, the splenic artery, the SMA, and the IMA. In the first picture here, you can see a longitudinal view of the ciliac and SMA. And then in trans, in the other picture, shows the hepatic and the splenic coming off the ciliac artery. Your angle of installation should be as close to 60 degrees as possible. Note that it's always easier to obtain 60 degrees in a longitudinal plane most of the time. The angle at rest should be similar to the angle with deep inspiration for consistency with the Doppler shift. We know when you have go from a 60 degree angle to a zero degree angle, the result will change in velocities with or without a maneuver. So it's always best to be consistent. So the criteria for ciliac and hepatic and splenic should be about under 200 centimeters per second with low resistance waveforms. The SMA and IMA should have high resistance waveforms with velocities under 275 centimeters per second. Now in a patient that has median arcuate ligament, one of two things can happen. When the patient has males, the median arcuate moves up in the diaphragm, releasing the compressed ciliac artery, and the ciliac artery velocities decrease with inspiration. Or, you can have no change in the position of the median arcuate ligament, and the ciliac artery velocities stay the same. Therefore, males will not be present in those patients. Now in testing for males, I'm going to reiterate this again. Without males, there is no significant change in the ciliac artery velocities from resting to deep inspiration. As you can see in the picture below with the patient without males, the ligament is above the level of the ciliac artery. Now with males, the resting ciliac arteries should be generally above 200 centimeters per second. And then there's a significant decrease in the ciliac artery velocities with a deep inspiration, usually greater than 60 centimeters per second in change. Now you can see in the picture below there, the ligament is resting just on the ciliac artery. Now it is important to note that compression of the SMA, hepatic, and or splenic arteries is also possible. When you do have this, you should evaluate these vessels at rest, have them take a deep inspiration and evaluate the vessels again, and then determine if compression is present. So in the pictures you see above here, the SMA in the top portion has a resting velocity of 364 centimeters per second. Now the picture below has the SMA with a deep inspiration and a velocity of 281 centimeters per second. That's a decrease of 83 centimeters per second, so it's pretty significant. So when males is present, there are often post-genetic responses that we do see. Turbulent waveforms are often present within the splenic and hepatic arteries. As you can see in the picture below, there's quite a respiratory variation, but you can see the turbulent waveforms. And then there's often elevated velocities present, and then there's post-genetic dilatation of the distal ciliac artery often present, like in the CTA picture next to it. There's this portion right here, the origin where it's narrowed, and then it looks much larger. So when males is present, there's often a J-shaped curve to the vessel at rest, which straightens out with deep inspiration. So you can note in the two pictures here, the real curvature of the ciliac artery as it comes around off the aorta. Now, this picture shows the straightening out of the vessels, so the first one you can see in B-mode, the celiac artery on the left has that real sharp curve, and then the picture right next to it shows the vessel with a deep inspiration, so a full straightening out of that vessel as the ligament comes off the vessel. And then again, in color, the picture next to it, you can see the curvature of the celiac artery, and then as they take the deep breath, the inspiration, the celiac artery straightens out. So this one, this should be a clip we can see of the live action of the celiac artery straightening out. Let me get this to play here. I'm sorry, everyone. I can't get rid of the stupid laser pointer. Bear with us. We were having some technical difficulties here. Missy, how do you get rid of the stupid laser pointer? Do you know? I'm so sorry, Mary Beth. It's okay. There you go. So here it is. You can see the celiac artery fully taking a different shape as the patient takes a deep inspiration. It hooks from the left and then it goes to the right as it straightens out. So there are different treatment options for males. There's an open surgical repair, which is not very common, and it involves a long incision through the abdomen, or the more common approach is the laparoscopic robotic surgical repair. This involves about five to six small incisions through the abdomen, and then there is a release or decompression of the median arcuate ligament, as well as the celiac plexus gets ligated and should result in some relief of the celiac artery. So during the laparoscopic approach, there is also an intraoperative duplex that is performed. Now, we do this after the resection has already been performed. So you obtain resting velocities of the celiac artery at rest of the supraceliac aorta, the osteoproximal and distal segments at rest, and since you can't do a deep inspiration while the patient is intubated, we have the anesthesiologist hold a Valsalva, and then obtain the velocities within the celiac artery at the osteoproximal and distal segments. And why do we do this? We do this, one, to make sure that the overall celiac velocities have decreased at rest, and then we also check to make sure that there is no respiratory variation with maneuvers. So you can see in the top picture, this is before the release, you can see all the ligaments over the vessels, and then in the bottom picture, you can see the actual vessels underneath all that resected, those fibrous bands and the median argot ligament. So let's go over a few case studies. The first one I'm going to go over with you guys is a 14-year-old female. She complains of pain with meals and exercise, often bloating, and she has a history of fibroids and irregular menstrual cycles. So she's been lumped into a different category for years of just having generalized pain from her menstrual cycles. So we start off with our supraceliac aorta. Now, note that the velocity in the aorta is 197, which is fairly high, but she's a young female patient, so we'll often see velocities that high in the aorta. And then the velocities at rest. So there's two pictures here to demonstrate the celiac artery osteovelocities at rest. So she goes from 440 centimeters per second to 450 centimeters per second at rest. We like to just make sure that we can replicate those velocities and obtain multiple ones throughout the exam. And now, if you look at her celiac artery with deep inspiration, she drops down to 257 and 292 centimeters per second. And then the distal portion of the celiac artery at rest, she's at 245 centimeters per second and then drops down to 159 centimeters per second with a deep inspiration. And now you can note the change in the shape of vessel from that J-shaped hook to the straightening out with deep inspiration. So the picture on the left has that clear hook and then the picture on the right shows the straightening out of the vessel. So on CT, she has a large J-shaped hook in the celiac artery consistent with compression by the median arcuate ligament. This one is a very clear case, so you can see the first branch coming off there of the celiac artery. So, the finding is in conclusion. So, this patient does have elevated velocities throughout the celiac artery at rest, which do not normalize with deep inspiration. The celiac artery decreases by 165 centimeters per second with the deep inspiration, and at the distal portion, it decreases by 85 centimeters per second with deep inspiration. And while there's no set criteria regarding the specific velocity range with deep inspiration, at the University of Chicago, we use a decrease of 60 centimeters per second from resting to deep inspiration, which is considered significant. So, a correlative CTA states that there's males as well as duplex ultrasound stating that there's males in this patient. So, what happened next? This patient went for a laparoscopic resection of the median arcuate ligament and the complex resection of the right and left crest of the diaphragm. A thoracolumbar sympethymy and a celiac and splenic block, as well as drainage of the left paraphylobium cyst. So, during the interoperative celiac artery duplex, the resting celiac artery velocities were 137 over 23. The proximal with a valsalva was 220 over 32, and then in the distal, it went from 156 centimeters per second to 188 centimeters per second with valsalva. So, it's good to note that the angle of insulation was closer to 60 degrees with the valsalva maneuver, accounting for the slight increase in velocities from resting to the valsalva. So, this is her post-operative duplex. Her aorta is at 163 now. Her proximal celiac artery is at 183, and the distal is at 193, so all within the normal range. With deep inspiration, there's no significant change. She goes from 183 to 180, and then in the distal segment, she goes to 197, so virtually no change in velocities with deep inspiration post-operatively. So, how's the patient feeling, which is the most important thing? She has better pain management with no postprandial pain and reports more ease with eating. She has a five-pound weight gain, and she still reports bloating in the lower abdomen, which is likely related to her fibroid and cystic abnormalities that were noted prior to the surgery. So, case study number two. This is a 15-year-old female. She complains of eating after all foods. She has no significant past medical history, no weight loss, just pain after eating everything. So, she was at an outside institution. She had conflicting reports. The CTA reported no males, and duplex reported males, so next step was to repeat the duplex at our institution. So, as we start here again, we start with the supraciliac aorta. She has a velocity of 206 centimeters per second, so note again that that's high. However, that's pretty normal in young pediatric patients, and the proximal ciliac artery resting was at 187, and then proximal with deep inspiration, she goes down to 147, so no real significant change there, and then the distal ciliac artery also evaluated. Her highest velocity noted was 224 centimeters per second, and then with deep inspiration down to 203 centimeters per second, so does this patient have males? So, our conclusion came up with, while there is no aortic to ciliac artery ratio criteria, there must be some hemodynamic consideration when evaluating young patients with exceptional cardiac output, so aortic velocity is considering above 200 centimeters per second. The resting distal ciliac artery velocities in this patient are of questionable significance. The peak systolic velocity of the aorta is 206, and the resting distal ciliac artery is 224. That's a 1.08 ratio, which is not very significant. Therefore, this patient with a 18 centimeter per second difference from the ciliac artery at rest compared to the aorta is not hemodynamically significant, so correlative CTA states that there is not males present in this patient, as well as by duplex. No males was present, so why is diagnosing males so tough? Patients have other diagnosed disorders. They have no reported weight loss. They just have a hard time putting on weight. The testing may not be done properly. Testing may not be ordered based on patients' multiple symptoms. There are a number of different reasons why a patient takes so long to get to the vascular lab. So, our final conclusions or takeaway from this is that males is a condition that causes multiple different abdominal symptoms. Diagnosis is often difficult due to nonspecific symptomology. It can be disguised as other pathologies. Surgical intervention is often necessary for treatment, and it typically requires a multidisciplinary approach with a team comprising gastroenterologists, vascular surgeons, a psychiatrist, and a general surgeon. Here's my references, and I'm here for questions if anybody has any. Thank you, Mary Beth, for the presentation. We do. We have a number of questions, and I'm going to try to get through as many of them as we can. So, the first question is, do you know what POTS is? You listed that as a differential diagnosis, I think, early on. Yes, POTS is a posterior... Let me get the exact word here for you. POTS syndrome is a posterior orthostatic tachycardia syndrome, so it's reduced, basically, with the blood volume, and it occurs when standing up, so the syndrome is triggered when a person stands or lying down, so many patients tend to have pain, but it's more related to their posture with the regards to the diaphragm being attached properly to the spine. Okay, and can you define, during the talk, you mentioned we took this velocity at rest, so can you talk about that a little bit? Yes, so when you're taking a velocity at rest, you don't want to have the patient take in a deep breath. You don't want to have them cease breathing. You just want them to breathe as normal as possible. I often see people who have patients, okay, stop breathing right now. Don't have them do that, because they tend to hold in their breath and tend to take in a small breath when they're doing it. Just have them rest as normal as possible and then obtain your velocities. Okay, very good. Do you have the patient stand and reassess for straightening of the celiac artery? We do not at our institution. I know some places have done this. We have seen that there's no change and there's no criteria stating from standing to laying down, which is why we don't perform that. Next question is, can a celiac compression get worse with forced expiration? Have you ever noticed that? No, so we do see orders that come through from doctors that say, with inspiration and expiration. The reason we do not do that at our institution, again, is, one, there's no criteria, and then, two, most people don't walk around pushing out all their breath and have symptoms with that. Most people are breathing, and so you want to get what is the most accurate day-to-day for that patient, so to speak, so you don't want them, you know, holding their breath or pushing it all out. Do you believe adolescent females with MALS will ever outgrow the syndrome as they get older? That's a great question, but no. The ligament is there, as far as I know, and the position that it's at is something anatomical. It's an anatomical variation for people, so where it's at in the abdomen is pretty much where it's at unless it's resected. Who performs the surgeries in your institution? So, we have a team of people, like I said. We have a gastroenterologist, a vascular surgeon, a psychiatrist, and a general surgeon. The two doctors that perform the surgery at our hospital are a vascular surgeon and a pediatric general surgeon. Have you ever seen this syndrome in older adults, or is it mostly young adults? We do see it quite a bit in older adults, and I think the reason we see it in older adults more is that they have had other issues their entire lives and have never had this testing done, so many people go on with, you know, saying that they have, you know, acid reflux or they have, you know, Crohn's disease or they have this, so the testing for this is just not done, and then after they've had, you know, years and years of treatments for Crohn's or for acid reflux, they still have this pain, and they just can't live like this, and then they get to that point where they're going to seek other opinions, and then they wind up in our vascular lab. Do you see many males with this condition? We do. We do see quite a few males as well, but the general population that we do see is a lot of younger females present with this, and it is something that we do see quite a bit, but males, it's definitely still there. Don't rule it out. Just because you have a male patient doesn't mean that they don't have it. Do you change the position of the patient at all when you're scanning, like scan them sitting or make them stand up? So, there is no, I would say right or wrong way. I have them lay as flat as I can, because that's typically the position people are in, whether they're standing or sitting. Ergonomically speaking, it is very hard to do an exam with the patient sitting or standing up. You'll realize that most people are very uncomfortable, so doing that and getting accurate velocities is a very challenging thing to do as a sonographer, so whether they're laying down or sitting up, it shouldn't change the hemodynamics in that artery, but make it easier on yourself and have them lay flat so you can get a more accurate depiction of what's going on. Okay, if everyone could bear with me now, there's a question to go back to the velocity criteria slide again, so we're going to scroll back. If you want to tell me when to stop, Mary Beth. Yeah, keep going towards the beginning. So, the waveforms in the ciliac, hepatic, and splenic should be low-resistant and under 200 centimeters per second. In the SMA, it should be under 275 centimeters per second, as well as in the IMA with high-resistant waveforms. Now, like I said, you will have some patients who have a really good cardiac output and have, you know, an aortic velocity of 220 or 190 centimeters per second, and then you look at the ciliac artery and it's two-tenths, and there's no change. You know, it's an inspiration. That's when you really have to look at your hemodynamics and see if you have any other things that you should be looking for, so people who have MALS, they tend to have that turbulent waveform in their splenic and hepatic, as well as maybe a post-sonic dilatation of the ciliac artery distally. Those are things to consider, too, when you're scanning. If you get a velocity of 210 and it goes down to 202 or 290, is it significant for that patient? Look for that about 60 centimeters per second change in your resting to deep inspiration. Yep, that was one of the questions, if there were specific velocities ratio criteria, like pre and post inspiration, or do you just look for a big change? So, you look for a big change. As of right now, there is no diagnostic criteria out. We like to do a correlative CT to demonstrate that there is compression on the patient, so if we have a suspicion for MALS but not quite getting the velocities we need, whether it be a subpar image or the patient can't tolerate the pain or we're just not seeing it as well, then we do a correlative CT. Okay, you have a couple comments that the images are very nice and they'd like to know what machine you're using. Most of those are on a mine ray, a Resna 7. Okay. And then, to be clear, compression relieved by inspiration and straightened out. Yes, so the celiac artery will tend to straighten out, not always, depending on how severe the compression is, but the celiac artery tends to go from that J-shaped hook at rest to straightening out, so it goes more towards the right of the screen with that deep inspiration, because that ligament is coming up off the vessel and it then straightens out and kind of follows the same path as, like, the SMA. Do you know, do they have to have a correlative CTA with a positive ultrasound to consider doing surgery, or do they ever just do it based on the ultrasound? I'm sure every institution is a little bit different. I think our doctors weigh pretty heavily on our duplex and more along the patient's symptoms. That's one of the biggest questions they ask their patients, you know, post-operatively. How are you feeling? There's also a component of the celiac plexus being divided out when they do the resection, so there's often a nerve block that's applied to these patients, too, so their overall is trying to get these patients nourished again. Most of these patients come in malnourished because they aren't eating enough, so if they can get the patients to eat and the blood flow is of normal supply, they've done their job, so I think that's really one of the things that they look for. Are these patients usually really thin, or can they be, you know, maybe a bigger, a normal weight or overweight, any patients? Yeah, you can have patients of all, you know, body types coming in for these. I think the most common thing we see, obviously, is the thin patients who've had a weight loss or are unable to put on weight. However, you do have a lot of people that have just adjusted their eating habits. You'll hear most patients say in the beginning, you know, if I eat a larger meal, my stomach hurts worse. Well, why is that? Because the larger the meal that you're having, the heavier it is, the more it takes to break down, the more blood flow your gut is going to need to break down those foods, so most people, what they've done is they've learned to just eat smaller amounts of food, and more often, which is what we should all do ideally, but they've done that, but maybe maintain their weight or put on weight because of the way they have eaten their lives. So you'll see that generally in patients that are a little bit older who have learned to adjust how to eat so that they don't get the pain. Have you ever noted a patient that was treated for MALS by stenting the celiac? I believe they do that in some of the patients that are a little bit older who have developed what they call like a webbing in the celiac artery after they have gone for years and years of not having any relief. So they develop this kind of string-like webbing inside the celiac artery and it creates a stenotic waveform, static velocities, and essentially a stenosis in there. So they have stented some of those patients. I don't know what the exact number is, but I do know that there's been some patients who, after the resection, have wound up with stents. Okay. Mary Beth, they'd like to go back and take a look at the protocol slide now. So is this the best one? So that's the B-mode images. If you go back one more maybe or, yeah, here we go. So the duplex protocol. So with color and Doppler, you want to evaluate all these arteries at rest and in the longitudinal plane. So that first image that you see there, you would go just proximal to the celiac artery and obtain your supraceliac aorta. And then you would go through and step your cursor through and make sure you're obtaining the highest velocity of your celiac, your SMA, and then your hepatic and splenic and IMA. And can you say where your criteria came from so other labs can review for documentation or their own documentation? Yeah, it's at the end of my slide there. It's all the way at the end. Okay. I'm getting fancier here, guys. So I'm going to the very end and we'll blow it up again. It's MONADA. It's MONADA criteria. So that second reference there. Okay. And, okay, we did the protocol slide again. Do you see spells across all ethnicities? That's a great question. Are there people who are more at risk from a genetic standpoint? That's a great question. I actually don't have the answer to that and it would probably be interesting to see. I'm not sure of that one. I can be honest with you. Yeah, that would be something very interesting to study. Yeah. All right. And, yeah, I think that we've covered most of our questions. If anybody has any last minute questions that they'd like to get in the chat box, please type away. Well, okay. Let's see. Okay. How about when scanning viscerals, should we always try to have the patient do deep inspiration after getting the resting velocity? So I don't think you need to do this for every single patient. I think this is patient specific. I don't think you need to do this for every single patient. I think this is patient specific. I don't think you need to do this for every single patient. I think this is patient specific. I don't think you need to do this for every single patient. I think this is patient specific. I don't think you need to do this for every single patient. I think this is patients that people are genuinely concerned for males with. If you start doing that with every single patient, I think you may have kind of a hard time. But your patients who have specific symptoms and your vascular surgeon is thinking, hey, they may have this, then it's good to run it by them. But I don't think as far as a everyday protocol, it's really necessary. What is the youngest patient you've ever seen with males? I will be honest with you, we have patients as young as like nine and 10 by us. So it's very, I think it's becoming more and more aware in different institutions and people are more willing to look at this to see if that's what's really going on with these patients. A lot of patients, unfortunately, get lumped into the category of they have an eating disorder because they say they have this fear of food. So unfortunately, they start having psychiatry involved and all that kind of stuff. But no testing is really done other than to make sure their gallbladder is okay. So this is one of those things I think that people need to dig a little deeper on sometimes. For all the patients that present for this evaluation, how many would you say turn out to be positive versus having normal velocities? So we do have a specialty doctor at our institution who specializes in males specifically. So we do get people from all over that present with this condition. So we do have a specialty doctor from all over that present with this. I couldn't give you a number of how many become our positive for males, but we do see it quite often and we do see it in a younger population more likely than the older population. It's usually those 15 to 32-year-olds that you see come in with this postprandial pain that no one can seem to figure out. Elimination diets aren't working and certain medications aren't working and they just have this pain. Okay. So how many mesenteric scans do you think you do in a year? You would probably answer that better than me. How many do we probably do in a year? We do a couple hundred, less than 500. At one time, renals were the highest volume that we did, but within the past couple of weeks, probably because we do a specialty clinic, the tables have turned and now we're doing more mesenteric than renals. Yeah, absolutely. We do a lot of mesenteric, not only just for males, but for just generalized abdominal pain. I think people are becoming a little bit more aware that, hey, they can look at this without getting a CT exam. And so it's a lot cheaper and easier for patients to withstand. So we do do quite a few of those abdominal exams. I will say viscerals are high on our list for what we do. Here's a good question. With males, how is Doppler flow and velocities affected in the hepatic and splenic? Have you noticed anything? Yeah, so definitely. So if you have a patient who has males and they have elevated velocities, you'll often see very turbulent flow and higher velocities in the hepatic and splenic. Now, I don't know generally how it affects the organs, but it does affect the hemodynamics and blood flow. You will definitely see a change in waveforms. You'll see more turbulence noted. In some severe cases, we do have, we do see patients that have a completely occluded celiac artery at rest. And then when they take a deep inspiration, you will see blood flow return to the celiac artery and their velocities are usually very high, like five, 600, 700. And you'll see a retrograde hepatic usually supplying flow then to the celiac artery and or to the splenic artery. So it's real important to note your direction of flow, because if you do have a severe compression of the celiac artery, you will tend to see retrograde flow in your hepatic, but that's usually over a long-standing situation. That's something you'll normally see in like your older patient population. Who reads the studies when the patient's a pediatric patient? Our vascular surgeons still do read them. They are not read by the pediatric surgeons. Everything that we do in our vascular lab is read by vascular attendees, but they do have a collaborative team that they consult with. Like I said, they see gastro, they see pediatrics, and then they'll see the vascular doctor as well as psych. Right. Highly specific to each office and institution who would be reading it. Absolutely. Yep. It depends on your institution specifically. What is the most common symptom patients present with? So would it be diarrhea, fear of food, reflux, or vomiting? So I, you know, the most common thing that you'll hear from patients is that fear of food. They literally just don't want to eat because they know as soon as they eat, it's going to hurt. So I think post-prandial pain is probably the most common one. And then also we hear a lot of pain with exercise and after eating. So, or after exercise and working out, you'll hear a lot of patients say, you know, I'm fine. And then I work out and I have this pain. Well, you're using those muscles and those ligaments are tightening and going straight across your arteries. So it does tend to hurt more. Mary Beth, why do you think the patients need to have a psych workup? So, like I said, a lot of patients, unfortunately, get lumped into this category of having an eating disorder. So to ensure that they are not having issues with food in general, just having a fear of food, or they just don't want to eat. So that's one of the reasons that they go there. Also, most of the patients that we do deal with are pediatrics. So there is a component just to make sure that there's not a lack of nutrition for the patients as well. Have you ever noticed a patient being referred because they've had brui on physical exam? Yes. So again, so when you have MALS, it creates a stenosis in those arteries. So the flow in it is definitely high and you will hear it. But I feel like that happens more so in the elderly population. Okay. This is another very good question. Do any of the patients have anomalous celiac arteries, anatomically, or no celiac maybe, but the hepatic and splenic coming off the aorta? Have you ever noticed that? I have not with these patients specifically. What I have noticed, like I said, is that the celiac artery is so tightly compressed that there is no flow at rest. And then as I add they take that deep inspiration, the ligament comes up and there's flow to that celiac artery without the compression there. I don't necessarily think I see a anatomical variation in patients as far as where the hepatic and splenic are coming off or if they have a common trunk with the SMA. But I do think the proximity of the SMA to the celiac artery does have a play. The proximity of the SMA to the celiac artery does have a play in it. If the ligament is very tight, it tends to create a compression on the SMA as well. Do you notice that the IMA is more prominent when a patient's positive for MEL? I have not noticed anything like that. There's often, like I said, these patients are usually young. So when we're seeing them, they haven't developed that collateralized flow. So no, not necessarily a difference in the IMA. Maybe if there's a component to the SMA as well, but no, not to the IMA as much. Okay. Do you happen to remember the prognosis of some of the patients you spoke about who had that complete celiac artery occlusion, even if it's just for a moment? Like their treatment that they've had? Yeah. Were they treated the same way? Do you know? I'm not sure if they were treated the same way. I do know we have one patient that we have followed that did have the release and they are much better postoperatively. The velocities are still extremely high at rest. I want to say they're about, so pre-surgery, they were occluded at rest. And then when they took a deep breath in, it ranged from about 600 to 700 centimeters per second at the origin of the celiac artery. And then intraoperatively went down to about 400 at rest. And I think they remain about in the 400 category. But now you have a patient who's had a compression for a long time and it's so severe that the vessel has to, takes time to normalize almost because it has that severe kink to it because of the amount of time that it's had that compression on it. So it's not going to straighten out immediately, especially in the patients that have had this for a long time. Have you ever tried to measure a volume flow in addition of velocity? I have not. I have not. And I don't think that there's any criteria on that. All right. I see those questions coming in. You guys have some great questions today. If a younger patient comes in for a gallbladder scan, do these symptoms and the scans negative, would it be beneficial for the patient to get a quick, like, a valve of the celiac with the protocol? So yeah, I mean, that's going to be based on your institution and what the doctor's Obviously, one of the most important things I always tell people is to make sure that these patients are MPO before they have these exams. As you know, with hemodynamics, it will change if a patient is postprandial, you tend to have higher velocities at rest after they have eaten. So it's important that they're, one, not eating, one, haven't eaten. And then two, see what their actual symptoms are. A lot of patients do have so many, so many symptoms that they don't know what's going on. They do have so many different things going on. It's helpful to take a look at the whole picture of the patient. You know, are they somebody who is a little bit larger? Are they very thin? Do they, have they had this for a long time? Do they notice pain with all foods or just certain foods? Is it something that they have, you know, dealt with, but it's gone away and it's come back? Those are things to ask the patients. And then, you know, maybe talk to your attending and see what they think. But I wouldn't just go out and do that test without, you know, talking with somebody first. But I think if you have a younger patient who is chronically dealing with postprandial pain, it's something that they should maybe investigate. Right. Or, or I would say, you know, if you put the probe down and you see an incidental finding. That's awesome, something to do. If you're right in the face, like some screaming celiac velocity or color flow, you should probably mention that. Your due diligence and note it. Offline or online, whichever you choose. Yeah, absolutely. If you find a high velocity, say something greater than 200 centimeters per second in the celiac and the patient symptomatic, do you still do the whole protocol, the rule out males, or do you say it's a celiac artery stenosis? So are you referring to like any patient at all, or a patient specifically coming in for a rule out males? Yeah, I think they're saying like, if you right off the bat find a velocity greater than 200 centimeters per second, do you go, do you always go through the whole protocol? I think so. I think we do. I do. Yeah, you should go through your whole protocol. One, you want to make sure there's no other vessel involvement. Two, you should have the documentation that there is a significant decrease. You have to note those things so that you can take a note for post-operative purposes if they do have surgery, or overall just to see if things are getting worse. You know, patients can have worsening of symptoms, and those are things that you would want to note, but you always want to complete your whole protocol. And Mary Beth, we talked about scanning the patient in different positions. Did you specifically talk about like standing them and doing it? Yeah, so that was one of those things I said, you know, it's very unfriendly to do a standing exam ergonomically. I think it's more difficult to get an accurate velocity with the patient standing. You have your arm extended, you know, while the patient's standing, and then you just have these fine movements. You know, these vessels are very tiny and small, and I think you have, leave yourself open to a lot of room for error if you do have the patient standing. The takeaway, I guess, is that if you have a compression of the celiac artery, you're going to have it, you know, laying down or sitting up. You're in the same sort of position, but when the diaphragm moves up and that ligament comes up with the deep inspiration, that's when you get the change in hemodynamics. Yes. All right. You know, we only have a few more minutes, so I think we're going to wrap it up here. Thank you, Mary Beth, for that presentation. Yeah, thanks everybody for joining us tonight, and again, great questions. Before we sign off, I want to remind everyone that this webinar was recorded, and it will be available online through the SVU website at NoChargeForAttendees. So there were a couple questions about how do I get credit for the CME and my CMEs. So again, watch your inbox. You're going to get an email from SVU to get your certificate. We have several webinars in the works covering some new topics, including changes to ARDMS requirements that are coming down the pike, and how we maintain our credentials. We're going to talk about work-related injury and ergonomics for the sonographer. We're going to talk about fibromuscular dysplasia and review of the new carotid consensus criteria, just to name a few of the talks that are in the works. We may have one more webinar in early November, or we might break for the holidays and just start meeting again in mid-January. So I hope you'll join us next time. Please look out for some communication from SVU on upcoming events. Thank you everybody for joining us tonight, and until next time, everyone take care and stay well. All right, thank you everybody. I appreciate you jumping on this evening.

MALS

abdominal condition

pain after eating

diagnostic criteria

celiac artery

treatment options

laparoscopic robotic surgical repair

case studies

nonspecific symptomology