Clinical recognition of mid-aortic syndrome in children

Mid-aortic syndrome is characterized by narrowing of the abdominal aorta, usually with the involvement of renal arteries and other visceral branches. The combination of the presence of an abdominal bruit, diminished or absent pulsations of the lower extremities, and a blood pressure discrepancy between upper and lower extremities is the classic triad associated with mid-aortic syndrome. However, it has a wide variety of clinical symptoms, and awareness of the variable presentation can lead to early diagnosis of the vascular anomaly. We report three cases presenting at three different stages of this disease, such as hydrops fetalis, refractory hypertension, and intracerebral bleeding. In conclusion, these cases highlight the importance of blood pressure measurements in all patients and accurate physical examination for early recognition of a mid-aortic syndrome.

Rare urogenital malformation associated with complex vascular malformation -- case report

BACKGROUND

Class 3 urogenital malformations are a rarely encountered in the clinical setting. The association with complex vascular malformations represent a challenge in diagnosis and intraoperative management with an enhanced degree of the complexity.

CASE PRESENTATION

Young female presented to the emergency department with pain in the left lower quadrant and unspecific abdominal symptoms that appear regularly one week prior and during her menstruation. Diagnostic studies and intraoperative findings lead to the diagnosis of a rare urogenital malformation associated with complex vascular malformations. In conclusion the most helpful diagnostic study was the abdominal MRI. Regarding the functional status of the postoperative urogenital tract no clear assessment can be made yet.

Mid-aortic syndrome in a 3-year-old girl successfully treated by aorto-aortic grafting and renal artery implantation into the graft

Mid-aortic syndrome, an uncommon acquired or congenital condition characterized by segmental narrowing of the abdominal or distal descending thoracic aorta, is frequently accompanied by ostial stenosis of the aorta's branches. If left untreated, it can result in life-threatening complications secondary to severe hypertension.We report the case of a 3-year-old girl with congenital mid-aortic syndrome, who was diagnosed by chance in the course of a viral illness, and whose high blood pressure values were first dismissed as inaccurate. Attempts to achieve medical or endovascular control of her hypertension were unsuccessful. She was thereafter successfully treated by aorto-aortic bypass grafting, resection of the stenotic segments of both renal arteries, and implantation of the patent arterial segments into the graft.

Mid aortic syndrome: a rare vascular disorder

Coarctation of abdominal aorta, Middle aortic syndrome (MAS) is a rare disease with only 200 reported cases. MAS may present clinically as uncontrolled hypertension, abdominal claudication or lower limb claudication. Surgical treatment is effective in controlling symptoms and improves life expectancy. We present another case of this rare entity, diagnosed and treated at Armed Forced Institute of Cardiology and Combined Military Hospital, Rawalpindi. This is the second reported case of MAS diagnosed and treated in Pakistan.

A case of the inferior mesenteric artery arising from the superior mesenteric artery in a Korean woman

Anatomical variations of the inferior mesenteric artery are extremely uncommon, since the inferior mesenteric artery is regularly diverged at the level of the third lumbar vertebra. We found a rare case in which the inferior mesenteric artery arose from the superior mesenteric artery. The findings were made during a routine dissection of the cadaver of an 82-yr-old Korean woman. This is the tenth report on this anomaly, the second female and the first Korean. The superior mesenteric artery normally arising from abdominal aorta sent the inferior mesenteric artery as the second branch. The longitudinal anastomosis vessels between the superior mesenteric artery and inferior mesenteric artery survived to form the common mesenteric artery. This anatomical variation concerning the common mesenteric artery is of clinical importance, performing procedures containing the superior mesenteric artery.

Multiple aberrant coeliac trunk ramifications

This study describes a routine educational cadaveric dissection, where multiple aberrant coeliac trunk branches were noticed. Specifically, the accessory left hepatic artery emerged from the left gastric artery, while the left inferior phrenic artery originated from the coeliac trunk. The accessory left suprarenal artery was found to commence from the coeliac trunk, whereas two aberrant left suprarenal arteries branched separately from the origin of the left inferior phrenic artery. Finally, the accessory jejunal artery was observed to originate from the coeliac trunk. Anatomical variations of the coeliac trunk branches can significantly alter the surgical management of the upper abdomen; hence, clinicians and radiologists should be aware of such aberrant vascular anatomy so as to reduce the incidence of surgical complications.

Anomalous origin of the right pulmonary artery from the abdominal aorta with aberrant right subclavian artery and left patent ductus arteriosus

Anomalous origin of the pulmonary artery (AOPA) from the aorta is a rare congenital heart malformation. This report describes a case of AOPA from the abdominal aorta in association with an aberrant right subclavian artery and a patent ductus arteriosus, which never has been reported previously in the literature.

Multiple variations of the abdominal aorta in a single cadaver

Numerous variations of the abdominal aorta were observed during a routine dissection of the abdominal region in a 60-year-old male cadaver in the Department of Anatomy, Meram Faculty of Medicine, Selcuk University, Turkey. In the present case, a common inferior phrenic trunk arose from the abdominal aorta and then divided into two branches. The left gastric artery arose from the front of the abdominal aorta, with an accessory right hepatic artery arising from the superior mesenteric artery. Although the single right renal artery originated from the abdominal aorta, double left renal arteries were found to originate from the abdominal aorta. Knowledge of these variations could help surgeons to identify and protect the abdominal aorta during surgery.

[A rare vascular malformation of the lung: discussion of the CT findings and nomenclature]

OBJECTIVE

To investigate the characteristic findings of an anomalous systemic arterial supply to the lung without the pulmonary artery on spiral CT and discuss its nomenclature.

METHODS

Four cases of anomalous systemic arterial supply to the left basal segment of the lung without the pulmonary artery were retrospectively reviewed with analysis of the characteristic CT findings.

RESULTS

On spiral CT scans, the involved left lower lung including the entire left basal segments (n=2), the lateral and posterior basal segment (n=1), and the anterior, medial, and posterior basal segment (n=1) had mild volume loss and areas of ground-glass opacity but with normal bronchial trees. The absence of the entire or part of the basal segments of the normal left lower lobar pulmonary artery, anomalous systemic artery originating from the abdominal aorta, diffuse dilatation of the systemic arterial branches distributed in the basal segments of the left lower lobe, and left lower pulmonary venous drainage into left atrium were found in all these patients.

CONCLUSION

This anomaly presents with characteristic findings on chest spiral CT, for which the nomenclature of local absent pulmonary artery better shows the characteristics of the disease.

Hepato-spleno-mesenteric trunk: a case report

Hepatic, splenic and left gastric arteries are the "classical branches" of celiac trunk. The authors report a rare variation, hepato-spleno-mesenteric trunk with two classical branches of celiac trunk and superior mesenteric artery having common origin from the abdominal aorta. The third classical branch of the celiac trunk (left gastric artery) was directly arising from the abdominal aorta. Knowledge of variations concerning the celiac trunk and superior mesenteric arteries are of great important for both surgical approaches and angiographic examinations.

Multiple variations in the branching pattern of the abdominal aorta

We report on a unique clinically and surgically significant case of multiple abdominal aorta variations. Specifically, the left inferior phrenic, left gastric and splenic artery arose in common from the left aspect of the aorta constituting a common phrenogastrosplenic trunk, while the common hepatic artery originated separately from the midline of the anterior aspect of the aorta just inferiorly to the trunk. An accessory right hepatic artery arises from the right-anterior aspect of the abdominal aorta adjacent to superior mesenteric artery origin. On the left side, two renal arteries were observed. Moreover, the left gonadal artery exhibited a high origin, arising inferiorly to the upper left renal artery. We discuss about the embryological development of abdominal aorta arterial abnormalities and we attempt to sort the noticed variations according to existing classification in the literature. It is highlighted that the thorough knowledge of these arterial variations is important for the success of upper abdomen surgical operations such as liver and kidney transplantation, kidney preservation, abdominal aorta related vascular surgery, treatment of hepatocellular carcinoma by transcatheter arterial chemoembolizations as well as imaging interpretation of the region. Preoperative selective angiography or other abdominal aorta imaging studies are helpful for arterial variation demonstration and a precious tool for appropriate surgery planning.

Bifurcated Abdominal Aorta, with a Coarctation over the Right Branch of the Bifurcated Abdominal Aorta and Aberrant Renal Arteries Originating from the Left Branch of the Bifurcated Abdominal Aorta

This study describes an unusual case of secondary hypertension in a young female patient presenting with severe hypertension and abdominal bruits. Gadolinium-enhanced MRA revealed a clearly bifurcated abdominal aorta, with a coarctation over the right branch of the bifurcated abdominal aorta and aberrant renal arteries originated from the left branch of the bifurcated abdominal aorta. Of interest is conventional angiography had failed to reveal these vascular abnormalities. This study mentions both embryologic and clinical aspects of this developmentally abnormal bifurcated abdominal aorta, coarctation of abdominal aorta and aberrant renal arteries.

Bilateral triple renal arteries

Knowledge of the variations of the renal artery has grown in importance with increasing numbers of renal transplants, vascular reconstructions and various surgical and radiologic techniques being performed in recent years. We report the presence of bilateral triple renal arteries, discovered on routine dissection of a male cadaver. On the right side, one additional renal artery originated from the abdominal aorta (distributed to superior pole of the kidney) and one other originated from the right common iliac artery (distributed to lower pole of the kidney). On the left side, both additional renal arteries originated from the abdominal aorta. Our observation has been compared with variations described in the literature and their clinical importance has been emphasized.

Mid-aortic syndrome with renovascular hypertension and multisystem involvement in a girl with familiar neurofibromatosis von Recklinghausen type 1

OBJECTIVES

Neurofibromatosis von Recklinghausen type 1 (NF1) is an autosomal dominant neurocutaneous disorder affecting one in 3 000-4 000 individuals. Mid-aortic syndrome (MAS) is a rare condition characterized by segmental narrowing of abdominal aorta and stenosis of its major branches - mainly renal arteries, including manifestation of renovascular hypertension. MAS can be caused by different diseases, including NF1.

MAIN FINDINGS

A 9 years old girl with primary diagnosis of NF1 combined with renovascular hypertension due to MAS, suffered of bilateral optic and chiasm glioma, pubertas praecox, speech disorder, light mental retardation and scoliosis. We have found a mutation in exone 34 of the NF1 gene (17q11.2). Her father has been also diagnosed with NF1 and hypertension developed at early age. He has the same mutation in exone 34 of NF1 gene. The girl is currently treated with conservative antihypertensive medication with positive effect. Bilateral optic and chiasm glioma are asymptomatic at the time and they had been without progress over period of time. Any vascular surgery, neurosurgical and oncological therapy are not indicated at the present time.

CONCLUSION

This article is a summary of clinical findings in patient with NF1 due to NF1 gene mutation in exone 34. It confirms the importance of complex multidisciplinar approach to examination and taking care of NF1 patients and their families.

[Rare variation of abdominal aorta breaking in two]

OBJECTIVE

To discuss a rare variation of abdominal aorta breaking in two.

METHODS

An in-patients, female, aged 76, admitted for asthenia of right extremities, underwent gadolinium-enhanced magnetic resonance angiography (MRA) of cerebral and abdominal vessels and abdominal MRI in whom the conventional angiography had failed to reveal this vascular abnormality.

RESULTS

MRA showed a clearly separated abdominal aorta. The upper part of the abdominal aorta terminated under the two renal artery branches and the lower part terminated at the level of L(3 - 4). The compensated enlarged superior and inferior mesenteric artery connected these two isolated parts of abdominal aorta.

CONCLUSION

This rare variation of abdominal aorta without any symptom is probably caused by some external force during the embryonic period.

A novel formula for the classification of blood vessels according to symmetry, asymmetry and hypoplasia

A new mathematical formula for calculating the symmetry, asymmetry and hypoplasia of blood vessel segments is presented for discussion. The study was conducted using the computed tomography (CT) files from 80 patients (34 men and 46 women) from the Silesian University Hospital, Silesia, Poland, who were between the ages of 12 to 76 and had undergone CT angiography of the circle of Willis. With the use of Gradual Angiographic Image Data Analyser software and double shuttled glasses, CT files were reconstructed. In addition, 80 renal arteries (RAs) from spontaneously aborted foetuses ranging in age from 14 to 30 weeks (24 male and 16 female) were injected with latex and also included in the study. Digital images of the RAs were taken using a Camedia 4040 camera and analysed using original analysis software. A novel formula entitled the Vascular Asymmetry Coefficient (VAC) was derived for this purpose and displays the differences between the mean diameters of blood vessel segments expressed as a percentage of the wider vessel with respect to the major diameter. The asymmetrical classification for a vascular segment of a vessel is given when the difference between the mean diameters of the vascular segment, as represented by the wider vessel, is greater than VAC > 10%. The hypoplastic classification is reserved for blood vessels where the difference between the diameter of the two segments is expressed as a percentage of the wider vessels and is greater than VAC > 40%. While there have been inconsistent and arbitrary classifications for the qualitative criteria of blood vessels, this newly presented algorithm can be used as a standardised tool and has a considerable range of uses, particularly when comparing blood vessel symmetry, asymmetry and hypoplasia prior to bifurcation, and unification.

Percutaneous Nitinol Stent Implantation in the Treatment of Nutcracker Syndrome in Young Adults

The present report describes three young adults with nutcracker syndrome caused by left renal vein stenosis managed with nitinol stent implantation. The patients treated included a 20-year-old woman with persistent microhematuria and dyspareunia and two 18-year-old men with proteinuria, hematuria, and flank pain. All three patients were asymptomatic after a follow-up of 14-18 months.