Coarctação de aorta abdominal justarrenal associada à hipertensão renovascular e claudicação incapacitante: tratamento utilizando ponte ilíaco-birrenal e técnica “paving and cracking”
Coarctation of the abdominal aorta associated with renovascular hypertension and incapacitating claudication: repair with iliac-birenal bypass and paving and cracking technique
Mateus Picada Corrêa; Francisco Costa Beber Lemanski; Jaber Nashat Saleh; Rafael Stevan Noel; Renan Camargo Puton; Julio Cesar Bajerski
Coarctation of the abdominal aorta is a rare etiology of intermittent claudication and refractory hypertension. Treatment is complex and requires knowledge of several vascular reconstruction techniques. We report a case of aortic coarctation at the level of the renal arteries, describing its treatment and presenting a literature review. Female patient, 65 years old, with refractory hypertension since the age of 35, using five antihypertensive medications at maximum doses. Blood pressure was 260/180mmHg and she had disabling claudication (less than 20 meters). Computed tomography angiography showed a 4mm coarctation in the juxtarenal aorta, with circumferential calcification at the stenosis site, and tortuous infrarenal aorta. Hybrid repair was performed with an iliac-birenal bypass and implantation of an Advanta V12 stent at the stenosis site. The patient’s postoperative course was satisfactory, she was free from claudication, and her blood pressure 60 days after surgery was 140/80mmHg, taking two antihypertensive medications.
1 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(6):774-81.
2 Rumman RK, Nickel C, Matsuda-Abedini M, et al. Disease beyond the arch: a systematic review of middle aortic syndrome in childhood. Am J Hypertens. 2015;28(7):833-46.
3 Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle WT, Correa A. Prevalence of congenital heart defects in metropolitan Atlanta, 1998-2005. J Pediatr. 2008;153(6):807-13.
4 Cohen JR, Birnbaum E. Coarctation of the abdominal aorta. J Vasc Surg. 1988;8(2):160-4.
5 Sen PK, Kinare SG, Engineer SD, Parulkar GB. The middle aortic syndrome. Br Heart J. 1963;25(5):610-8.
6 Stanley JC, Criado E, Eliason JL, Upchurch GR Jr, Berguer R, Rectenwald JE. Abdominal aortic coarctation: surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft. J Vasc Surg. 2008;48(5):1073-82.
7 Delis KT, Gloviczki P. Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment. Perspect Vasc Surg Endovasc Ther. 2005;17(3):187-203.
8 Sandmann W, Dueppers P, Pourhassan S, Voiculescu A, Klee D, Balzer KM. Early and long-term results after reconstructive surgery in 42 children and two young adults with renovascular hypertension due to fibromuscular dysplasia and middle aortic syndrome. Eur J Vasc Endovasc Surg. 2014;47(5):509-16.
9 Ghazi P, Haji-Zeinali AM, Ghasemi M, Pour MZ. Transcatheter stent implantation for the treatment of abdominal aortic coarctation and right renal artery stenosis in takayasu’s arteritis: a case with a 4-year follow up. Hellenic J Cardiol. 2011;52(2):182-5. PMid:21478132.
10 Savlania A, Parameshwarappa SK, Viswanathan S, Raman KT, Madathipat U. Extra-anatomic neo-aorta for adult abdominal aortic coarctation. ANZ J Surg. 2014;84(12):988-90.
11 Moresco KP, Shapiro RS. Abdominal aortic coarctation: CT, MRI, and angiographic correlation. Comput Med Imaging Graph. 1995;19(5):427-30.
12 Iwata A, Takahashi Y, Ohgi K, Sakuta M. A case of spinal hemorrhage associated with abdominal aortic coarctation. Rinsho Shinkeigaku. 1997;37(5):413-6. PMid:9294331.
13 Mallios A, Boura B, Combes M, Blebea J. Abdominal aortic coarctation in a middle aged adult. J Vasc Surg. 2015;61(1):240.
14 Koksal C, Demirci S, Koksal GM, Zengin M. An infrarenal abdominal aortic coarctation. Surg Radiol Anat. 2005;27(1):71-3.
15 Nawa S, Ikeda E, Kubo M, et al. Multisaccular aneurysm developing in association with abdominal aortic coarctation: report of a surgical case. Ann Thorac Cardiovasc Surg. 2003;9(5):326-9. PMid:14672531.
16 Paroni R, Astuni M, Baroni C, et al. Abdominal aortic coarctation inducing aortic occlusion and renovascular hypertension. J Cardiovasc Surg. 1991;32(6):770-4. PMid:1752897.
17 Graham LM, Zelenock GB, Erlandson EE, Coran AG, Lindenauer SM, Stanley JC. Abdominal aortic coarctation and segmental hypoplasia. Surgery. 1979;86(4):519-29. PMid:483161.
18 Breckwoldt WL, Mackey WC, Belkin M, O’Donnell TF Jr. The effect of suprarenal cross-clamping on abdominal aortic aneurysm repair. Arch Surg. 1992;127(5):520-4.
19 Yokoyama N, Nonaka T, Kimura N, et al. Acute kidney injury following elective open aortic repair with suprarenal clamping. Ann Vasc Dis. 2020;13(1):45-51.
20 Oderich GS, Gloviczki P, Bower TC. Open surgical treatment for chronic mesenteric ischemia in the endovascular era: when it is necessary and what is the preferred technique? Semin Vasc Surg. 2010;23(1):36-46.
21 Hinchliffe RJ, Ivancev K, Sonesson B, Malina M. “Paving and cracking”: an endovascular technique to facilitate the introduction of aortic stent-grafts through stenosed iliac arteries. J Endovasc Ther. 2007;14(5):630-3.