Current Evidence on the Treatment of Median Arcuate Ligament Syndrome: A Comprehensive Review

Median arcuate ligament syndrome (MALS) is an uncommon and controversial disorder characterized by chronic abdominal symptoms associated with extrinsic compression of the celiac artery (CA) and adjacent celiac plexus by the median arcuate ligament (MAL). Although anatomical CA compression is relatively common, only a small proportion of individuals develop clinically significant disease, making accurate diagnosis and patient selection fundamental to successful treatment. This narrative review critically evaluates the current evidence on the management of MALS, focusing on patient selection, the role of celiac plexus blockade, operative decompression techniques, adjunctive revascularization, treatment outcomes, and postoperative surveillance. A comprehensive literature search of PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library was performed up to June 2026, with an emphasis on clinical guidelines, systematic reviews, multicenter studies, and comparative series. Contemporary evidence supports a multidisciplinary, exclusion-based diagnostic approach, integrating compatible symptoms with dynamic vascular imaging, while recognizing that radiographic CA compression alone is insufficient to establish the diagnosis. Surgical MAL release, often combined with celiac plexus neurolysis, remains the cornerstone of treatment, with minimally invasive approaches generally favored because of lower perioperative morbidity and faster recovery. Primary endovascular treatment without ligament release is not recommended, whereas staged revascularization should be reserved for selected patients with persistent symptoms and objectively significant residual stenosis after adequate decompression. Despite encouraging outcomes in carefully selected patients, the available evidence is limited by retrospective study designs, heterogeneous diagnostic criteria, inconsistent outcome reporting, and a lack of randomized controlled trials. Future prospective studies and standardized reporting are required to optimize patient selection and establish evidence-based treatment algorithms.