Median arcuate ligament syndrome (MALS) is typically treated surgically, with around 80% of patients having some level of symptom improvement during follow-up periods of 6 months or less. There is limited data beyond this time frame, as well as on the patients who do not experience symptom improvement or recurrence of symptoms and how to treat such cases. This chapter reviews our current understanding of long-term outcomes, potential factors that may predict improvement, presentation of residual and recurrent MALS, and how to address these cases.