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Surgical treatment of middle aortic syndrome due to Takayasu arteritis
VASCULAR IMAGES
Surgical treatment of middle aortic syndrome due to Takayasu arteritis Young-Wook Kim, MD,a Kiick Sung, MD,b Yang Jin Park, MD,a and Duk-Kyung Kim, MD,c Seoul, Korea A 35-year-old Korean female patient presented with symptoms of postprandial pain and claudication in both lower extremities, with increasing serum creatinine. Her blood pressure at presentation was 170/91 mm Hg on antihypertensive medications, and blood tests showed elevated serum creatinine (2.07 mg/dL) and erythrocyte sedimentation rate (39 mm/dL), and anemia (10.0 g/dL). The C-reactive protein level was within the normal reference range (0.2 mg/dL). A three-dimensional volume-rendered image of a posterior view thoracoabdominal computed tomography (CT) scan showed a heavily calcified distal thoracic and abdominal aorta and a contracted left kidney (A). The axial CT view showed the paravisceral aortic diameter was narrowed to 5.5 mm (B). On a diagnosis of middle aortic syndrome (MAS) due to Takayasu arteritis (TA), we performed an aortic bypass from the ascending aorta to the aortic bifurcation in conjunction with revascularization of the right renal and superior mesenteric arteries. On postoperative day 1, the patient’s serum creatinine level recovered to a normal range and her postprandial abdominal pain subsided. A postoperative CT angiogram showed patent aortic, renal, and mesenteric bypass grafts (C/Cover). DISCUSSION TA often affects the thoracic or abdominal aorta, or both, and their primary branches. According to the classification of International TA Conference in Tokyo in 1994, lesions confined to the distal thoracic and abdominal aorta on angiogram, with or without renal artery, involvement are classified as type III.1 Our previous review of 208 TA patients found 3.8% of patients corresponded to type III.2 Aortic coarctation located in the distal thoracic aorta or abdominal aorta, or both, is called MAS or “midaortic dysplastic syndrome.”3 MAS patients clinically present with renovascular hypertension, chronic renal insufficiency, and chronic mesenteric or leg ischemia. Endovascular treatment can be attempted for the treatment of this condition; however, the severe aortic wall calcification or acute inflammation of the involved vessel wall, or both, usually precludes the use of endovascular treatment. Before deciding a treatment strategy for patient with MAS due to TA, disease progression, durability of the treatment, particularly in younger patients, comorbidities, and risks related with the treatment should be considered. After open reconstructions of the aorta, renal, and mesenteric artery, we found improved renal function, postprandial pain, and leg claudication.
From the Division of Vascular Surgery,a Department of Thoracic and Cardiovascular Surgery,b and Division of Cardiology,c Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;62:750-1 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.05.017
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JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
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REFERENCES 1. Hata A, Noda M, Moriwaki R, Numano F. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol 1996;54(Suppl):S155-63. 2. Lee GY, Jang SY, Ko SK, Kim EK, Lee SH, Han H, et al. Cardiovascular manifestations of Takayasu arteritis and their relationship to the disease activity: Analysis of 204 Korean patients at a single center. Int J Cardiol 2012;159:14-20. 3. 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;194:774-81. Submitted Sep 5, 2013; accepted May 6, 2014.
Surgical treatment of middle aortic syndrome due to Takayasu arteritis Young-Wook Kim, MD,a Kiick Sung, MD,b Yang Jin Park, MD,a and Duk-Kyung Kim, MD,c Seoul, Korea A 35-year-old Korean female patient presented with symptoms of postprandial pain and claudication in both lower extremities, with increasing serum creatinine. Her blood pressure at presentation was 170/91 mm Hg on antihypertensive medications, and blood tests showed elevated serum creatinine (2.07 mg/dL) and erythrocyte sedimentation rate (39 mm/dL), and anemia (10.0 g/dL). The C-reactive protein level was within the normal reference range (0.2 mg/dL). A three-dimensional volume-rendered image of a posterior view thoracoabdominal computed tomography (CT) scan showed a heavily calcified distal thoracic and abdominal aorta and a contracted left kidney (A). The axial CT view showed the paravisceral aortic diameter was narrowed to 5.5 mm (B). On a diagnosis of middle aortic syndrome (MAS) due to Takayasu arteritis (TA), we performed an aortic bypass from the ascending aorta to the aortic bifurcation in conjunction with revascularization of the right renal and superior mesenteric arteries. On postoperative day 1, the patient’s serum creatinine level recovered to a normal range and her postprandial abdominal pain subsided. A postoperative CT angiogram showed patent aortic, renal, and mesenteric bypass grafts (C/Cover). DISCUSSION TA often affects the thoracic or abdominal aorta, or both, and their primary branches. According to the classification of International TA Conference in Tokyo in 1994, lesions confined to the distal thoracic and abdominal aorta on angiogram, with or without renal artery, involvement are classified as type III.1 Our previous review of 208 TA patients found 3.8% of patients corresponded to type III.2 Aortic coarctation located in the distal thoracic aorta or abdominal aorta, or both, is called MAS or “midaortic dysplastic syndrome.”3 MAS patients clinically present with renovascular hypertension, chronic renal insufficiency, and chronic mesenteric or leg ischemia. Endovascular treatment can be attempted for the treatment of this condition; however, the severe aortic wall calcification or acute inflammation of the involved vessel wall, or both, usually precludes the use of endovascular treatment. Before deciding a treatment strategy for patient with MAS due to TA, disease progression, durability of the treatment, particularly in younger patients, comorbidities, and risks related with the treatment should be considered. After open reconstructions of the aorta, renal, and mesenteric artery, we found improved renal function, postprandial pain, and leg claudication.
From the Division of Vascular Surgery,a Department of Thoracic and Cardiovascular Surgery,b and Division of Cardiology,c Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;62:750-1 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.05.017
750
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Kim et al 751
REFERENCES 1. Hata A, Noda M, Moriwaki R, Numano F. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol 1996;54(Suppl):S155-63. 2. Lee GY, Jang SY, Ko SK, Kim EK, Lee SH, Han H, et al. Cardiovascular manifestations of Takayasu arteritis and their relationship to the disease activity: Analysis of 204 Korean patients at a single center. Int J Cardiol 2012;159:14-20. 3. 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;194:774-81. Submitted Sep 5, 2013; accepted May 6, 2014.