73 / 76
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 2, March/April 2017
AFRICA
e3
fatal hypertension-related events). All cases with medically
resistant hypertension should undergo imaging of both the
descending thoracic and abdominal aortae to reveal any
potentially curable vascular pathologies.
In cases with MAS-induced poorly controlled hypertension,
early surgical treatment is recommended.
1-4
This strategy may
prevent the development of irreversible organ dysfunction.
Several surgical techniques have been described.
1-4
One is
endarterectomy, which should be avoided due to poor long-term
clinical results. Nowadays the most widely used surgical method
is aorto-aortic bypass with the use of prosthetic grafts.
Besides surgical approaches, the endovascular approach has
been developed recently, with some case reports in the literature.
It is based on the rapid evolution of thoracic endovascular aortic
repair (TEVAR) procedures in aortic coarctation, which could
become significant in the near future. Before surgery, our patient
was disqualified from the endovascular approach, based on the
opinion of the vascular team in our hospital (interventional
radiologist, vascular surgeon and cardiac surgeon). Total
occlusion of the supradiaphragmatic aorta is a contraindication
for the endovascular approach.
The effect of aortic reconstruction with aorto-aortic bypass
is usually permanent, irrespective of the aetiology. It should
also be recommended in view of the complexity of the aortic
lesions causing MAS, including diffuse pathology of the aortic
wall and adjacent tissues. Our case supports earlier reports
describing successful use of aorto-aortic bypass. In our patient,
a left thoraco-abdominal retroperitoneal approach to the normal
aorta above and below the lesions and lateral clamping of the
aorta were used. It enabled a good overview of the descending
aorta and facilitated proper selection of the sites of side-to-end
anastomoses.
Conclusion
This elective operation with a Dacron prosthesis was relatively
safe and it was confirmed as an effective method of treatment,
with marked postoperative reduction in arterial blood pressure.
However, this method required strict cooperation between
radiologist, and cardiac and vascular surgeons. We stress that a
multidisciplinary approach should be recommended in treatment
of this rare but complex aortic wall pathology.
References
1.
Petrunic M,Tonkovic I, Grabic D, Popovic L, Radanovic B, Kruzic Z.
Middle aortic syndrome: some diagnostic and therapeutic considera-
tions.
Eur
J Endovasc Surg
1999;
18
: 83–85.
2.
Connolly JE, Wilson SE, Lawrence PL, Fujitani RM. Middle aortic
syndrome: distal thoracic and abdominal coarctation, a disorder with
multiple etiologies.
J Am Coll Surg
2002;
194
: 774–781.
3.
Bobby JJ, Emami JM, Farmer RD, Newman CG. Operative survival
and 40 year follow up of surgical repair of aortic coarctation.
Br Heart
J
1991;
65
: 271–276.
4.
Segers B, Derluy M, Barroy JP, Brunet AP. Isolated supradiaphragmatic
descending thoracic aorta stenosis in a Takayasu’s disease: surgical cure.
Eur
J Cardiothorac Surg
2001;
20
: 1243–1245.