The relationship between the celiac axis and median arcuate ligament is dynamic. The resultant compression can lead to repetitive trauma of both the arterial wall of and the nerve plexus around the celiac axis. The arterial anatomy of the celiac axis, including the relevant network of collaterals, can give clues to understanding a patient’s symptoms and must be appreciated to formulate a repair strategy. We propose that, akin to thoracic outlet syndrome, the compression physiology of median arcuate ligament syndrome can take the forms of arterial and neurogenic MALS. Arterial MALS may manifest as aneurysm, dissection, or occlusive disease of the celiac axis or its branches. The presentations may range from symptoms of chronic mesenteric ischemia of the foregut to those of a symptomatic visceral aneurysm. Here, we present case examples demonstrating the principles of repair in arterial MALS from traditional open to endovascular modalities.