ACQUIRED COARCTATION OF
THE ABDOMINAL AORTA
WILLIAM J. McCANN, M.D., F.A.C.S., F.A.C.A.
coarctation of the thoracic aorta below first of coarctation of the abdominal aorta was case the ductus in 1835. The reported by Quain2 in 1847, and a second case was noted by Power3 in 1861. Reviews of the subject have been published by Maycock’ in 1937, Pollock-, in 1956, Sennin g6 and Godwin’ in 1959. In most instances the area involved has been at or near the renal arteries, though in some cases the celiac and or mesenteric arteries have been involved. Stenosis of a segment of the aorta may occur, but most often complete atresia of a segment of the aorta is reported. Acquired coarctation is not to be confused with &dquo;Pseudocoarctation&dquo; of the aorta; a congenital elongation of the vessel which results in kinking as originally described by Rosler and White8 in 1931. A variety of surgical procedures have been utilized in the management of this problem; including bypass grafts, 9 bypass with the splenic artery,lo, 11 resection with homograft,12, 13 or prothesis replacement,14 as well as thrombectomy.15 The present case is reported because of the unusual nature of the obstruction and the unique surgical correction, neither of which is believed to have been previously described.
Schlesinger~ reported the first case of
CASE REPORT
R.M. #4021739: A 62-year-old white female admitted to the
hospital
on
10-31-71, because of progressive bilateral intermittent claudication over the past year. The pain involved the calves, thighs, and hips of both lower extremities. Past History: Appendectomy in 1929; oral surgery in 1957 and 1959; hysterectomy for fibroids in 1958; excision of vulva cyst in 1963; excision of chalazion in 1969. Review of the hospital records for these admissions indicated that the blood pressure was 140/78 in 1957; 140/80 in 1959; 140/90 in 1963; and 180/100 in 1969. Physical Examination: Pertinent positive findings were: bilateral carotid bruits more marked on the left side. Heart sounds were normal. Rhythym was regular. There were no murmurs heard. Lungs were clear. No abdominal bruits were heard. Blood pressure was 180/100 in both upper extremities. Bilateral femoral bruits were heard. Femoral pulses were present, but diminished. Popliteal, dorsalis pedis and posterior tibial pulses were absent bilaterally. Oscillometric readings above the knee bilaterally were 0.25 and at the calf bilaterally were zero. There were no trophic changes in the lower extremities. Lab Data: The urine was normal. The hemoglobin was 14.8 grams. There were 4.3 million red blood cells. The white blood count was 8,700, and the differential was normal. An SMA-12 survey was normal. A PBD was 7.1 mg %. 29
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30 An electrocardiogram was interpreted as normal. The chest X-ray was normal. A right ileofemoral arteriogram failed to adequately visualize the lower abdominal aorta, but did demonstrate a segmental block in the right superficial femoral artery. A left axillary antegrade aortogram was attempted, but it was not possible to pass the catheter into the descending aorta. A left ileofemoral arteriogram was performed with good reflux into the terminal aorta. A sharp delineation of dye was noted with diluted contrast material in the aorta proximal to this sharp demarcation. (Fig. 1.) An aortic dissection was suspected. An intravenous aortogram via a catheter placed into the inferior vena cava was then performed. This study revealed a normal thoracic aorta. The abdominal films could be only interpreted as showing an abnormal configuration of the abdominal aorta below the renal arteries. The renal arteries themselves appeared normal. On 11-5-71, an operation was performed. The operative findings revealed a normal-sized distal aorta with diminished pulsations and a palpable thrill. These findings were present at a sharply delineated area approximately 4 cm below the left renal vein. A longitudinal aortotomy through this area revealed a localized diaphragmatic-type structure with a small perforation approxi-
FIG. 1. tion.
Retrograde aortogram demonstrating characteristic findings. Note post-stenotic dilata-
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
31
FIG. 2. Drawing demonstrating the location of the occlusion in the terminal aorta.
mately 0.5 cm in diameter. (Fig. 2.) The operation consisted of a &dquo;postage stamp&dquo; endarterectomy with removal of the diaphragm. (Fig. 3.) The aorta was then closed with a continuous suture. The postoperative course was uncomplicated. The postoperative blood pressure was in the range of 140/150 systolic with a diastolic pressure of 80/90 ml Hg. Distal arterial pulsations were restored. The patient was discharged on 11-27-71. DISCUSSION
Coarctation of the abdominal aorta manifested
by
atresia
or
stenosis is
an
unusual, but long-recognized pathologic entity. It is generally considered to be congenital in origin, and not to be confused with progressive arteriosclerotic obliteration of the terminal aorta described by Leriche.16 Martinez 17 has suggested that these atypical types of coarctation may be due to a nonspecific arteritis. Diaphragmatic occlusion of the terminal aorta has not, we believe, been previously described. The etiology in this case is uncertain, but the sequence of events would suggest recent origin. Involvement of other vessels with the arteriosclerotic process would suggest this as the possible etiology. The characteristic roentgenographic findings on the retrograde aortic study of good concentration of contrast material below the diaphragm, a sharplydemarked area devoid of contrast material, and a proximal faint outline of an otherwise normal proximal aorta, correlates so well with the gross pathology that once recognized, cannot ever again be misinterpreted.
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
32
FIG. 3.
Opened
resected
specimen showing perforated diaphragm. SUMMARY
An unusual case of aortic obstruction, not heretofore described, is presented. This obstruction consisted of a perforate diaphragm which occurred in the abdominal portion of the aorta below the renal arteries. Diagnosis and operative method are discussed with several references to the literature.
William J. McCann, M.D. Director, Dept. of Surgery New Rochelle Hospital Medical Center New Rochelle, N. Y. 10802
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
33 REFERENCES 1.
Schlesinger: Merkwurdige, Verschliessung der Aorta: Casper’s Wchnschr. 31:
2.
f.d. ges Heilk. No.
489, 1835.
Quain,
R.: Partial Contraction of the Abdominal Aorta. Trans Path. Soc. London. 1: 244,
1847.
Power, J. H.: Observation on Diseases of the Aortic Valves and Atrophy of Abdominal Aorta. Dublin Quart. J. Med. Sc. 32: 314, 1861 (citado por Bahnson). 4. Maycock, W. D’A: Congenital Stenosis of the Abdominal Aorta. Am. Heart J. 13: 633, 1937. 5. Immon, T. W., and Pollock, B. E.: Coarctation of the Abdominal Aorta: Review of the literature. Am. Heart J. 52: 314, 1956. 6. Hanson, J.; Ikkos, D.; Johansson, L.; Rudhe, U.; and Senning, A.: Coarctation of the Abdominal Aorta. Case report and description of successful surgical treatment. Acta chir. Scandinav. (Supp.) 245: 315, 1959. 7. Brust, A. A.; Howard, J. M.; Bryant, M. R.; and Godwin, J. T.: Coarctation of the Abdominal Aorta with Stenosis of the Renal Arteries and Hypertension. Amer. J. of Med. 27: 793, 1959. 8. Rosler, H., and White, P. D.: Unusual Variations of Roentgen Shadow of Elongated Thoracic Aorta. Amer. Heart J. 6: 768, 1931. 9. Gerbasi, F. S.; Kibler, R. S.; Margileth, A. M.: Coarctation of the Abdominal Aorta. A case successfully treated surgically. J. of Pediat. 52: 191, 1958. 10. Glenn, F.; Keefer, E. B. C.; Speer, D. S.; and Dotter, C. T.: Coarctation of the Lower Thoracic and Abdominal Aorta Immediately Proximal to Celiac Axis. Surg. Gyne. & Obstet. 94: 561, 3.
1952. 11. 12. 13.
14.
15. 16.
17.
Rob-London, C. G.; D’Alreu, A. L.; and Vollman, J. F.: Die Coarctatio
Aortae Abdominalis. Arch Klin. Chir. 292: 285, 1959. Cooley, D. A., and DeBakey, M. E.: Resection of the Thoracic Aorta with Replacement by Homograft for Aneurysms and Constrictive Lesions. J. Thorac. Surg. 29: 66, 1955. Guastavino, G., and Becu., L.: Coarctaciones aorticas ubicadas por debajo del sitio habitual. (Un case operado de doble coartacion. Reseccion y hominjerto.). Rev. Asoc. Med. Argent. 7: 347, 1956. Dillon, M. L.; Postlethwait, R. W.: Coarctation of the Abdominal Aorta: Report of a case and review of the surgical procedures. South. Med. J. 54: 295, 1961. Depraz, A.: Les formes basses du retrecissement congenital de l’aorte. These de Lyon, 1953, Eosc. Frises. Leriche, R.: De la Resection du Carrepour Aortico-Iliaque avec Double Sympathectomie Lombaire pour Thrombose Arteritique de l’Aorte; le syndrome de l’obileration termino-aortique par arterite. Presse Med. 48: 601, 1940. Torres, G.; Gonzalez, C.; Rodriquez, G.; and Martinez, A.: Atypical Coarctation of the Aorta Caused by Nonspecific Arteritis. Review of 19 cases. Arch. Inst. Cardiol. Mex. 40: 602, 1970.
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
THE ABDOMINAL AORTA
WILLIAM J. McCANN, M.D., F.A.C.S., F.A.C.A.
coarctation of the thoracic aorta below first of coarctation of the abdominal aorta was case the ductus in 1835. The reported by Quain2 in 1847, and a second case was noted by Power3 in 1861. Reviews of the subject have been published by Maycock’ in 1937, Pollock-, in 1956, Sennin g6 and Godwin’ in 1959. In most instances the area involved has been at or near the renal arteries, though in some cases the celiac and or mesenteric arteries have been involved. Stenosis of a segment of the aorta may occur, but most often complete atresia of a segment of the aorta is reported. Acquired coarctation is not to be confused with &dquo;Pseudocoarctation&dquo; of the aorta; a congenital elongation of the vessel which results in kinking as originally described by Rosler and White8 in 1931. A variety of surgical procedures have been utilized in the management of this problem; including bypass grafts, 9 bypass with the splenic artery,lo, 11 resection with homograft,12, 13 or prothesis replacement,14 as well as thrombectomy.15 The present case is reported because of the unusual nature of the obstruction and the unique surgical correction, neither of which is believed to have been previously described.
Schlesinger~ reported the first case of
CASE REPORT
R.M. #4021739: A 62-year-old white female admitted to the
hospital
on
10-31-71, because of progressive bilateral intermittent claudication over the past year. The pain involved the calves, thighs, and hips of both lower extremities. Past History: Appendectomy in 1929; oral surgery in 1957 and 1959; hysterectomy for fibroids in 1958; excision of vulva cyst in 1963; excision of chalazion in 1969. Review of the hospital records for these admissions indicated that the blood pressure was 140/78 in 1957; 140/80 in 1959; 140/90 in 1963; and 180/100 in 1969. Physical Examination: Pertinent positive findings were: bilateral carotid bruits more marked on the left side. Heart sounds were normal. Rhythym was regular. There were no murmurs heard. Lungs were clear. No abdominal bruits were heard. Blood pressure was 180/100 in both upper extremities. Bilateral femoral bruits were heard. Femoral pulses were present, but diminished. Popliteal, dorsalis pedis and posterior tibial pulses were absent bilaterally. Oscillometric readings above the knee bilaterally were 0.25 and at the calf bilaterally were zero. There were no trophic changes in the lower extremities. Lab Data: The urine was normal. The hemoglobin was 14.8 grams. There were 4.3 million red blood cells. The white blood count was 8,700, and the differential was normal. An SMA-12 survey was normal. A PBD was 7.1 mg %. 29
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
30 An electrocardiogram was interpreted as normal. The chest X-ray was normal. A right ileofemoral arteriogram failed to adequately visualize the lower abdominal aorta, but did demonstrate a segmental block in the right superficial femoral artery. A left axillary antegrade aortogram was attempted, but it was not possible to pass the catheter into the descending aorta. A left ileofemoral arteriogram was performed with good reflux into the terminal aorta. A sharp delineation of dye was noted with diluted contrast material in the aorta proximal to this sharp demarcation. (Fig. 1.) An aortic dissection was suspected. An intravenous aortogram via a catheter placed into the inferior vena cava was then performed. This study revealed a normal thoracic aorta. The abdominal films could be only interpreted as showing an abnormal configuration of the abdominal aorta below the renal arteries. The renal arteries themselves appeared normal. On 11-5-71, an operation was performed. The operative findings revealed a normal-sized distal aorta with diminished pulsations and a palpable thrill. These findings were present at a sharply delineated area approximately 4 cm below the left renal vein. A longitudinal aortotomy through this area revealed a localized diaphragmatic-type structure with a small perforation approxi-
FIG. 1. tion.
Retrograde aortogram demonstrating characteristic findings. Note post-stenotic dilata-
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
31
FIG. 2. Drawing demonstrating the location of the occlusion in the terminal aorta.
mately 0.5 cm in diameter. (Fig. 2.) The operation consisted of a &dquo;postage stamp&dquo; endarterectomy with removal of the diaphragm. (Fig. 3.) The aorta was then closed with a continuous suture. The postoperative course was uncomplicated. The postoperative blood pressure was in the range of 140/150 systolic with a diastolic pressure of 80/90 ml Hg. Distal arterial pulsations were restored. The patient was discharged on 11-27-71. DISCUSSION
Coarctation of the abdominal aorta manifested
by
atresia
or
stenosis is
an
unusual, but long-recognized pathologic entity. It is generally considered to be congenital in origin, and not to be confused with progressive arteriosclerotic obliteration of the terminal aorta described by Leriche.16 Martinez 17 has suggested that these atypical types of coarctation may be due to a nonspecific arteritis. Diaphragmatic occlusion of the terminal aorta has not, we believe, been previously described. The etiology in this case is uncertain, but the sequence of events would suggest recent origin. Involvement of other vessels with the arteriosclerotic process would suggest this as the possible etiology. The characteristic roentgenographic findings on the retrograde aortic study of good concentration of contrast material below the diaphragm, a sharplydemarked area devoid of contrast material, and a proximal faint outline of an otherwise normal proximal aorta, correlates so well with the gross pathology that once recognized, cannot ever again be misinterpreted.
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
32
FIG. 3.
Opened
resected
specimen showing perforated diaphragm. SUMMARY
An unusual case of aortic obstruction, not heretofore described, is presented. This obstruction consisted of a perforate diaphragm which occurred in the abdominal portion of the aorta below the renal arteries. Diagnosis and operative method are discussed with several references to the literature.
William J. McCann, M.D. Director, Dept. of Surgery New Rochelle Hospital Medical Center New Rochelle, N. Y. 10802
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
33 REFERENCES 1.
Schlesinger: Merkwurdige, Verschliessung der Aorta: Casper’s Wchnschr. 31:
2.
f.d. ges Heilk. No.
489, 1835.
Quain,
R.: Partial Contraction of the Abdominal Aorta. Trans Path. Soc. London. 1: 244,
1847.
Power, J. H.: Observation on Diseases of the Aortic Valves and Atrophy of Abdominal Aorta. Dublin Quart. J. Med. Sc. 32: 314, 1861 (citado por Bahnson). 4. Maycock, W. D’A: Congenital Stenosis of the Abdominal Aorta. Am. Heart J. 13: 633, 1937. 5. Immon, T. W., and Pollock, B. E.: Coarctation of the Abdominal Aorta: Review of the literature. Am. Heart J. 52: 314, 1956. 6. Hanson, J.; Ikkos, D.; Johansson, L.; Rudhe, U.; and Senning, A.: Coarctation of the Abdominal Aorta. Case report and description of successful surgical treatment. Acta chir. Scandinav. (Supp.) 245: 315, 1959. 7. Brust, A. A.; Howard, J. M.; Bryant, M. R.; and Godwin, J. T.: Coarctation of the Abdominal Aorta with Stenosis of the Renal Arteries and Hypertension. Amer. J. of Med. 27: 793, 1959. 8. Rosler, H., and White, P. D.: Unusual Variations of Roentgen Shadow of Elongated Thoracic Aorta. Amer. Heart J. 6: 768, 1931. 9. Gerbasi, F. S.; Kibler, R. S.; Margileth, A. M.: Coarctation of the Abdominal Aorta. A case successfully treated surgically. J. of Pediat. 52: 191, 1958. 10. Glenn, F.; Keefer, E. B. C.; Speer, D. S.; and Dotter, C. T.: Coarctation of the Lower Thoracic and Abdominal Aorta Immediately Proximal to Celiac Axis. Surg. Gyne. & Obstet. 94: 561, 3.
1952. 11. 12. 13.
14.
15. 16.
17.
Rob-London, C. G.; D’Alreu, A. L.; and Vollman, J. F.: Die Coarctatio
Aortae Abdominalis. Arch Klin. Chir. 292: 285, 1959. Cooley, D. A., and DeBakey, M. E.: Resection of the Thoracic Aorta with Replacement by Homograft for Aneurysms and Constrictive Lesions. J. Thorac. Surg. 29: 66, 1955. Guastavino, G., and Becu., L.: Coarctaciones aorticas ubicadas por debajo del sitio habitual. (Un case operado de doble coartacion. Reseccion y hominjerto.). Rev. Asoc. Med. Argent. 7: 347, 1956. Dillon, M. L.; Postlethwait, R. W.: Coarctation of the Abdominal Aorta: Report of a case and review of the surgical procedures. South. Med. J. 54: 295, 1961. Depraz, A.: Les formes basses du retrecissement congenital de l’aorte. These de Lyon, 1953, Eosc. Frises. Leriche, R.: De la Resection du Carrepour Aortico-Iliaque avec Double Sympathectomie Lombaire pour Thrombose Arteritique de l’Aorte; le syndrome de l’obileration termino-aortique par arterite. Presse Med. 48: 601, 1940. Torres, G.; Gonzalez, C.; Rodriquez, G.; and Martinez, A.: Atypical Coarctation of the Aorta Caused by Nonspecific Arteritis. Review of 19 cases. Arch. Inst. Cardiol. Mex. 40: 602, 1970.
Downloaded from ves.sagepub.com at NANYANG TECH UNIV LIBRARY on June 3, 2015
