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Coarctation of the abdominal aorta is an uncommon process but an important cause of systemic hypertension. Angiography is the investigation of choice to establish a diagnosis and document the extent of involvement. However, angiography does not provide an etiological diagnosis; and it may not be possible to distinguish an acquired coarctation from a congenital process. Three patients with coarctation of the abdominal aorta are presented.
Aortic coarctation is an uncommon condition complicating pregnancy and is associated with increased morbidity and mortality. Due to the perceived risk of aortic dissection/rupture during labor, the rate of cesarean delivery is higher in these women. We report a young woman with uncorrected coarctation of aorta who had two successive vaginal deliveries with successful maternal and neonatal outcome. Cesarean delivery is not mandatory for women with coarctation of aorta.
Coarctation of the abdominal aorta constitutes a rare group of vascular abnormalities, including segmental stenoses and extended hypoplasia. Hypertension is the usual solitary clinical finding and contrasts with the diversity of anatomic lesions and surgical techniques used for treatment. It is often difficult to determine whether the lesion is congenital or due to Takayasu's aortitis. Three cases of hypoplasia in adolescents are reported. Treatment consisted of an aortoaortic bypass in all cases. Vein angioplasty of the renal arteries was performed concomitantly in one case of inter- and infrarenal hypoplasia associated with stenosis of the two renal arteries. In one of the two cases of suprarenal hypoplasia, the celiac axis was reimplanted after excision of an associated aneurysm. In all three cases, blood pressure returned to normal values without medical treatment.
Coarctation of the abdominal aorta with stenoses or occlusions of the renal and mesenterial arteries was diagnosed in four patients. Three of the patients had severe hypertension and two had intermittent claudication. All the patients had normal arteries in the legs. The first patient was diagnosed i 1974 and was judged at that time to be inoperable. He is still alive, but suffers from severe hypertension and intermittent claudication. The other three patients were diagnosed later and have all been surgically treated, two with Dacron bypasses from the thoracic to the abdominal aorta, one of them with supplemental Dacron bypasses to both renal arteries, the celiac axis, and the superior mesenteric artery. The last patient had a Dacron prosthesis from the thoracic aorta to both common femoral arteries implanted. Post-operatively, the three patients operated on were free from symptoms and normotensive.
A second case of double coarctation of the thoracic aorta is reported, the first having been observed at the Marie-Lannelongue Surgical Center in an older child. This case was a 3 months infant in which the missed pre- and postoperative diagnosis led to reoperation after control catheter and angiographic studies. These investigations were carried out one month after the first operation because of persistent severe cardiac failure. Surgical cure in two stages consisted in a Waldhausen plastic enlargement procedure and a Crafoord-type resection anastomosis, ensuring the best chances for a good result.
Coarctation of the thoracic or abdominal aorta often is associated with reduced perfusion of one or both kidneys, resulting in severe renovascular hypertension, which significantly influences the spontaneous course of these patients. Fourteen of 15 patients who were operated upon between 1983 and 1996 suffered from arterial hypertension. Thirteen patients had ischemia of one or both kidneys resulting from renal artery stenosis or stenosis of the descending or visceral aorta. Because of a hemodynamically significant stenosis the aorta was reconstructed in 11 patients by interposition graft, bypass, or patchplasty. Concerned renal or visceral arteries were reconstructed by bypass/interposition graft, patchplasty, or reimplantation. One patient died, presumably from septic bleeding, 3 weeks post operatively. There was a cure of hypertension in 3 and an improvement in 6 patients. In the individual patient hypertension could be cured more often if the diagnosis of coarctation were established early.
Coarctation of the abdominal aorta remains a surgically treatable cause of hypertension in children and young adults. Average age of the patients is 21 years at the time of diagnosis and a second peak in the fourth to fifth decade. If left untreated, most patients die as a result of complications from untreated hypertension by the age of 35 years. Aortography remains the diagnostic test of choice with associated visceral and renal artery stenoses occurring in 26% of cases. Of the 146 cases reported, 109 had surgical treatment with an operative mortality rate of 6.9%. Of those patients having surgery 96% were normotensive or were easily controlled postoperatively with antihypertensive medications. Because claudication is a minor problem in most cases, surgical correction of the hypertension by hepatorenal or splenic-renal bypasses may be the preferred initial surgical treatment in patients without significant visceral artery involvement or severe symptomatic lower extremity ischemia.
Coarctation of the abdominal aorta represents an unusual but surgically treatable form of hypertension. The cause is somewhat controversial but generally can be traced to congenital or acquired origins. A case is presented in which the anomaly appears to be congenital. The variability in anatomy and subsequent treatment are discussed along with appropriate evaluation of the problem.
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Although coarctation of the aorta is associated with various cardiac abnormalities, its association with mitral annular calcification (MAC) is not reported. We therefore report a 37-year-old patient with postductal coarctation of the aorta and MAC. Considered to be a degenerative process, MAC is usually seen in elderly patients. It is uncommon in patients less than 50 years old and rare before the age of 40 years. Previous studies have reported increased frequency of cardiac conduction disturbances in patients with MAC compared to age- and sex-matched controls. This is in agreement with complete right bundle-branch block noted on the electrocardiogram of our patient. Clinicopathologic correlative studies and long-term follow-up may determine how such conduction disturbances develop and progress.
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A 18 year-old female was admitted to our hospital with hypertension of 190/100 mmHg in her right arm and 140/110 mmHg in the left arm. Femoral arterial pulsation was not palpable. Her physical status and growth of the lower limbs were normal. Aortography demonstrated slight coarctation with a pressure gradient of 10 mmHg and descending aortic stenosis with a pressure gradient of 80 mmHg. Main three branches from aortic arch were anatomically normal. However, the left subclavian artery distal to the origin of the left vertebral artery was not visualized and the axillary artery was perfused by collaterals. Atypical coarctation was replaced using a woven Dacron graft of 14 x 40 mm. Postoperatively proximal pressure decreased from 180/113 to 156/98 mmHg and there was no pressure gradient between proximal and distal of the graft. After six months blood pressure in the right arm gradually decreased to 120/78 mmHg.
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We present herein a case of ascending aorta to supraceliac abdominal aorta bypass for coarctation of the aorta in a 46-year-old woman with a history of hypertension. Because of severe calcification of the coarctation segment, we performed an ascending aorta to supraceliac abdominal aorta bypass instead of a conventional resection and anastomosis of the coarctation segment. Following surgery, the patient's blood pressure normalized, and she was discharged on the 14th postoperative day without any complications. An ascending aorta to supraceliac abdominal aorta bypass for coarctation of the aorta in adults is thus considered to be safe and easy to perform.
A 4 month-old boy who had double-inlet left ventricle, severe subaortic stenosis, hypoplastic ascending aorta and coarctation of the aorta revealed severe respiratory failure. An urgent Norwood operation was done. The procedure consisted of enlargement of the ascending aorta and main pulmonary artery and a systemic-pulmonary shunt using 5 mm PTFE tube. Postoperative course was uneventful.
Ten patients between the ages of 10 and 17 years underwent ascending aorta-descending aorta bypass grafts for recurrent coarctation at the Oregon Health Sciences University from 1975 to 1984. The combined approach through a left thoracotomy and median sternotomy was used in all the patients. This operation was used when the segment of recoarctation was long, dense adhesions were present, collaterals were inadequate, or when a cardiac operation was necessary for an associated lesion. All the patients survived the operation, and the long-term results to date have been satisfactory.
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The treatment of coarctation of aorta with an additional cardiac lesion in adults remains a difficult surgical challenge. We present here an alternative, two-stage, hybrid approach that combined stent repair of aortic coarctation followed by coronary artery bypass operation in an adult with critical coronary lesions and a poor ventricle. This method may be a potentially useful strategy in reducing the comorbidity of operation to both lesions.