ABSTRACT Introduction Pancreaticoduodenal and gastroduodenal artery aneurysms (PDAA and GDAA) are rare but life‐threatening vascular lesions. Many are associated with median arcuate ligament syndrome (MALS), a condition associated with increased retrograde collateral flow due to celiac artery compression. Although endovascular treatment is the first‐line approach for PDAA and GDAA, the role and timing of median arcuate ligament (MAL) release remain unclear. Methods This consensus statement was developed through the Anatomy on the Border Expert Consensus Meeting, organized by the Japanese Society for Endoscopic Surgery. Among multiple clinical questions (CQs) addressed by the working group, this statement focuses on CQ3: the appropriate timing of MAL release in patients with PDAA or GDAA associated with MALS. Consensus statements were developed based on a literature review, a nationwide survey, expert panel discussions, and a modified Delphi voting process. Results Although evidence remains limited, MAL release may improve antegrade visceral perfusion, prevent ischemic complications, reduce retrograde hemodynamic stress and recurrence risk, and facilitate vascular access for future interventions. Based on current evidence and expert input, the committee developed and approved three consensus statements: MAL release could be considered before endovascular treatment in clinically stable cases; Endovascular treatment should be performed first in ruptured cases, with careful attention to end‐organ ischemia; Elective MAL release is suggested after aneurysm treatment to reduce the risk of recurrence. Conclusion These consensus statements support individualized surgical decision‐making for patients with PDAA or GDAA associated with MALS, where evidence is limited and clinical practice varies.
UENO et al. (2026) studied this question.