Cardiovascular Journal of Africa: Vol 28 No 2 (March/April 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 2, March/April 2017 AFRICA e1
Successful surgical treatment of a subtotal descending
aortic occlusion
Mateusz Puślecki, Bartłomiej Perek, Sebastian Stefaniak, Andrzej Siniawski, Grzegorz Oszkinis, Marek
Jemielity
Abstract
We present the case of a 33-year-old man with middle aortic
syndrome. The final diagnosis was established with magnetic
resonance imaging. He underwent a successful aorto-aortic
bypass. Two-year follow-up imaging showed the new graft
was patent, with no abnormalities at the anastomosis sites. At
the last follow-up examination he was asymptomatic with no
neurological dysfunction.
Keywords: surgical treatment, subtotal aorta occlusion, descend-
ing aorta
Submitted 15/11/15, accepted 17/2/16
Cardiovasc J Afr 2017; 28: e1–e3
DOI: 10.5830/CVJA-2016-012
Middle aortic syndrome is a rare vascular anomaly, with a long
segment of stenotic descending thoracic and abdominal aorta.1-3
Its aetiology is not commonly known although in some cases,
chronic inflammation with mononuclear cell infiltration is
considered to be of importance, as in Takayashu disease. The
rarity of this entity encouraged us to share our experience. We
therefore present the case of a young man with middle aortic
syndrome who underwent successful surgery with a good late
outcome.
Case report
A 33-year-old man was examined because of hypertension
and easy fatigability of the lower extremities. The femoral
pulses were poorly present. His blood pressure, measured
indirectly at admission, was 180/120 mmHg at the brachial
artery and 90/70 mmHg in the thigh. His medical history
included isolated, poorly controlled arterial hypertension despite
aggressive pharmacotherapy (amlodipine, ramipril, nebivolol and
methyldopum). The resuts of routine laboratory examinations
were normal, including C-reactive protein and procalcytonin.
On admission, transthoracic echocardiography showed a left
ventricle with preserved systolic performance (left ventricular
ejection fraction 56%) and aortic valve with correct morphology
and function. Due to a slight dilatation of the ascending aorta
on routine examination (chest X-ray, echocardiography), he was
referred for magnetic resonance (MRI) imaging of the aorta.
On MRI, the ascending aorta and aortic arch were normal.
Approximately 25 mm distal to the left subclavian artery
orifice, a severely stenotic segment of the descending aorta was
visualised. Critical (3–4 mm) aortic coarctation was diagnosed.
It confined not only the thoracic aorta, but also the abdominal
aorta up to the coeliac trunk (total lesion length 180 mm) (Fig.
1). Moreover, the supradiaphragmatic descending aorta was
completely occluded. The aortic arch branches and coeliac and
renal arteries were normal without any changes compromising
flow. The collateral circulation was excessively developed,
predominantly through the intercostal branches and markedly
dilated left and right thoracic arteries (Fig. 1). In the narrowed
aortic wall, signal enhancement was noted in the short time
inversion recovery (STIR) MRI window, which suggested an
underlying chronic inflammatory process, or aortitis.
Surgery was performed through a left thoracotomy and
abdominal retroperitoneal approach by cardiac and vascular
surgeons. First, the descending aorta was side-clamped distal
to the left subclavian artery and a 22-mm-diameter prosthetic
vascular graft was anastomosed in an end-to-side fashion. Then
it was passed through a small incision in the left lateral portion
of the diaphragm. Eventually, distal anastomosis was performed
15 mm below the renal arteries to a macroscopically normal
aortic wall. During surgery, specimens from the anastomosis
sites were taken for histological examination.
The patient’s postoperative course was complicated by
transient paresis of the brachial plexus. Aggressive postoperative
rehabilitation at both the cardiac surgery department and
rehabilitation centre enabled complete functional recovery. After
surgery, there was no need for hypertensive agents and his arterial
Department of Cardiac Surgery and Transplantology,
Poznan University of Medical Sciences, Poznan, Poland
Mateusz Puś lecki, PhD, MD
Bartłomiej Perek, PhD, MD
Sebastian Stefaniak, PhD, MD,
Marek Jemielity, MD
Department of Cardiology, Poznan University of Medical
Sciences, Poznan, Poland
Andrzej Siniawski, PhD, MD
Department of Vascular Surgery, Poznan University of
Medical Sciences, Poznan, Poland
Grzegorz Oszkinis, MD
Case Report