[Abdominal vascular malformations and Down syndrome]

Malformations of the abdominal venous system are rare vascular disorders. These entities are associated with other malformations and with chromosomal anomalies such as trisomy 21. Abdominal venous malformations are probably the most frequent congenital vascular malformations in Down syndrome. Prenatal diagnosis allows the early follow-up and treatment of complications. We present a case of Down syndrome associated with an abdominal venous malformation diagnosed at the first trimester of pregnancy.

[Diagnosis and treatment of aneurysm in the common trunk of malformed superior mesenteric artery and celiac trunk]

OBJECTIVE

To explore the diagnosis and treatment of the aneurysm in the common trunk of malformed superior mesenteric artery and celiac trunk, especially the approach how to expose and excise such aneurysm.

METHODS

The clinical data of 6 patients with aneurysm in the common trunk of malformed superior mesenteric artery and celiac trunk, who were operated on under general anesthesia from 1998 to 2006, were analyzed. At first, the body of pancreas was isolated and retracted, the malformed celiac trunk and its ramification were blocked and ablated, the initial part of the celiac trunk and the distant end of left gastric artery were ligated, and then by-pass operation was operated from infra-renal aorta to the visceral arteries (hepatic, splenic, and superior mesenteric arteries) with artificial blood vessels. Follow-up was conducted for 1 - 8 years.

RESULTS

Five cases underwent aneurysm ablation and by-pass from aorta to hepatic, splenic, and superior mesenteric arteries; while 1 case underwent aneurysm ablation and spleen ablation, superior mesenteric artery reconstruction, and by-pass from aorta to hepatic artery simultaneously. All patients were cured without complication and recurrence. No arterial anastomosis stricture or stenosis was found in the 5 patients who received by-pass from aorta to hepatic, splenic, or superior mesenteric artery; however, slight stricture was found at the repaired portion of superior mesenteric artery in another one patient, but without any arterial anastomosis stricture in aorta or hepatic artery.

CONCLUSION

It is an effective and safe method to treat the aneurysm common trunk of malformed superior mesenteric artery and celiac trunk by using the artificial blood vessel by-pass from aorta to visceral arteries (hepatic, splenic, and superior mesenteric arteries) after controlling the initial part of common trunk and cutting off the aneurysm there.

Middle mesenteric artery: contraindication to endovascular repair of an abdominal aortic aneurysm?

Middle mesenteric artery has been described in 1923. We report the observation of a patient with an abdominal aortic aneurysm who had this rare artery arising from the anterior wall of the aneurysmal sac. His inferior mesenteric artery was occluded at its origin from the aorta and the middle and the distal colon was vascularized only by the middle mesenteric artery. Occlusion of this artery would have been necessary before endovascular repair of the aneurysm. We were concerned about the risk of colic ischemia after the occlusion of the middle mesenteric artery, so we abandoned this approach and operated on the patient via a laparotomy. Based on a case report, we here report a literature overview on the repair of abdominal aortic aneurysm in the presence of a middle mesenteric artery.

Vascular anomalies in a case of situs inversus

Situs inversus is a developmental condition in which the thoracic and abdominal organs fail to negotiate their normal migration patterns and the result is a mirror-image arrangement of these viscera. The literature provides evidence that individuals with this condition have a higher incidence of other congenital malformations (e.g. heart anomalies). Here we describe the dissection of a 71 year-old female cadaver with situs inversus, in which we discovered multiple anomalous vessels associated with the coeliac trunk directed toward the liver. In addition, we identified the inferior vena cava on the left side and a persistent supracardinal vein on the right, constituting a double inferior vena cava. Finally, we identified multiple abnormal venous channels associated with the sub-renal inferior vena cava. These vascular patterns are indeed a rare finding and have surgical implications but may indicate a higher incidence of vascular anomalies in cases of situs inversus.

Thoracoabdominal aorta coarctation with bilateral renal artery involvement: diagnosis with multidetector CT angiography (MDCTA)

Atypical coarctation of the descending thoracic and abdominal aorta is a very uncommon vascular disease. Congenital, acquired, inflammatory, and infectious etiologies have been proposed. Patients typically presents with uncontrolled secondary hypertension in the upper half of the body or hypotension in the lower extremities in the first three decades of their lives. We report the case of a 20-year-old man with severe hypertension. Diffuse coarctation of thoracoabdominal aorta associated with bilateral renal artery stenosis was demonstrated clearly by multidetector CT angiography. This is the first case of atypical aortic coarctation diagnosed by MDCTA.

Iatrogenic Aorto-Cisterna Chyli Fistula During Percutaneous Balloon Aortoplasty in a Patient with Takayasu’s Arteritis: A Case Report

We present a case of iatrogenic aorto-cisterna chyli fistula that developed during percutaneous transluminal aortoplasty in a 16-year old girl with Takayasu's arteritis. The aorto-cisterna chyli fistula was angiographically confirmed and treated using a stent-graft, which successfully occluded the fistula. Her claudication then improved, although follow-up CT angiography at 10 months revealed mild recurrent aortic stenosis.

Primary antiphospholipid syndrome associated with small aorta syndrome: a case report

It has been widely accepted that the antiphospholipid syndrome (APS) is an autoimmune hypercoagulability syndrome in which a variety of venous and arterial thrombotic events may occur. Peripheral obliterating arterial disease characterized by aortoiliac steno-occlusion occurring in young women, is reported in the literature under the name of Small Aorta Syndrome (SAS). Although it remains unclear whether SAS represents a separate entity, the small size of the distal aorta increases the risk for aortoiliac occlusive disease. A 41-year old white woman was admitted with acute digital ischemia of the left foot. She had positive lupus anticoagulant and IgG anti-cardiolipin antibodies (61 UI/mL), but antinuclear antibodies and anti-ds-DNA antibodies were negative. She previously had two deep venous thromboses of the legs and, despite the oral anticoagulant therapy, pulmonary embolism occurred. Shortly thereafter, abdominal angio-magnetic resonance imaging suggested that the infra-renal aorta was narrowed more than 50%, without thrombotic occlusion of the terminal aorta and common iliac arteries. These findings were compatible with the features of SAS. There were no atherosclerotic changes in the artery wall and no other prediposing risk factors such as smoking, oral contraceptive or hyperlipidemia. After adequate anticoagulation and intravenous prostacyclin treatment the patient's symptoms and the ischemic lesions improved markedly. To our knowledge this is the first report of the association of SAS and primary APS. The occurrence of SAS in patients with APS may dramatically increase the risk of trombothic events.

A critical analysis of minor cardiovascular criteria in the diagnostic evaluation of patients with Marfan syndrome

PURPOSE

The prevalence of most minor cardiovascular manifestations in Marfan syndrome (MFS) is unknown. We assessed the prevalence of minor cardiovascular manifestations in MFS to evaluate their usefulness in a diagnostic setting.

METHODS

Seventy-seven patients with MFS (aged 4 months to 55 years) underwent echocardiography to assess the presence of mitral valve prolapse and the diameter of the main pulmonary artery. A subset of 29 adult patients with MFS also underwent magnetic resonance imaging evaluation of the diameters of the thoracoabdominal aorta.

RESULTS

Mitral valve prolapse was encountered in 66% of patients with MFS, with an equal distribution of classic and nonclassic mitral valve prolapse. The main pulmonary artery diameter was significantly larger in patients with MFS at all ages when compared with controls. In the adult group (> or = 14 years), we were able to provide a cutoff value of 23 mm to define pulmonary artery dilatation. The descending aorta was enlarged, but with substantial overlap with controls, thus precluding the use of a cutoff value.

CONCLUSIONS

Mitral valve prolapse and main pulmonary artery dilatation are common findings in MFS patients at all ages and are easy to assess with echocardiography. Cutoff values to define dilatation of the descending aorta are hard to define, making them of limited value in the diagnostic evaluation. We recommend echocardiographic evaluation of mitral valve prolapse and main pulmonary artery diameter in patients referred for cardiovascular diagnostic assessment for MFS.

Caudal regression sequence: vascular origin?

Caudal regression sequence (CRS) is a rare congenital defect of the lower spinal segments and the neural tube. Motor symptoms as well as neurological deficits and loss of bladder and bowel function are usually present. CRS is also associated with anomalies in other systems such as the gastrointestinal and genitourinary tract. Etiology and pathogenesis are poorly understood.A newborn presented with anomalies of the spinal column (lumbosacral) with absence/hypoplasia of the 12th thoracic and first lumbar vertebral anomaly body. Bladder and bowel initially were functional. MR-angiography exhibited an anomaly of the unpaired vessels originating from the aorta, a likely relict of a persisting vitelline artery. These findings indicate a potential vascular genesis of CRS, much as in sirenomelia.

Rare association of severe hypoplasia of the abdominal aorta with imperforate anus, colonic atresia, and choledochal cyst

Hypoplasia of the abdominal aorta (HAA) is a rare condition that causes marked hypertension. Although multiple etiologies have been postulated for HAA, congenital structural anomalies are rarely observed except in cases associated with some hereditary syndromes. The authors describe a neonatal case with HAA complicated by multiple anomalies including colonic atresia (CA), imperforate anus, choledochal cyst, facial cleft, and brain defects. This patient showed CA in the descending colon and caliber change in the transverse colon mimicking Hirschsprung disease, both of which were thought to be caused by vascular insult to the mesentery due to HAA. Although multiple surgical corrections were successfully performed, the hypertension was uncontrollable.

[Duplication of the inferior vena cava: anatomical dissection and clinical implications]

The duplication of the inferior vena cava is often incidentally discovered during radiological studies. The presence of this anomaly can be mistaken for retroperitoneal adenopathy. Its knowledge allows to avoid hemorrhagic complications during retroperitoneal surgery. An anatomical dissection of a duplication of the inferior vena cava is presented. Embryogenesis and variations are described. Radiological and clinical implications are discussed.

Multiplicity of the variations in ventral branches of abdominal aorta

Numerous variations of the ventral branches of the abdominal aorta were observed during routine dissection of the abdominal region in a 63-year-old male cadaver in the Department of Anatomy at Ege University Medicine Faculty. The branches of the celiac trunk were arising from two different trunks as the upper and below ones. The trunk at the upper was gastrophrenic trunk and the trunk at the below was hepatosplenic trunk. The superior mesenteric artery arose from the front of the abdominal aorta just below the hepatosplenic trunk. The relations of the right testicular artery was also unusual. Although the variations of the abdominal aorta branches are common the present case is interesting because of the multiplicity of the variations. The knowledge of these variations could be useful for clinicians for recognition and protection.

Diagnosis of abdominal aortic hypoplasia by state-of-the-art MR angiography

Abdominal aortic hypoplasia is a rare vascular variant with possible major clinical sequelae when the renal arteries are also involved. The condition is thought to result from embryonic overfusion of the two dorsal aortas. The diagnosis may be considered in patients presenting with hypertension in the neonatal period and severely reduced or absent arterial pulses in the groin. We present contrast-enhanced state-of-the-art magnetic resonance angiography imaging findings in an 8-year-old boy with abdominal aortic hypoplasia.

An anomalous case of the left gastric artery, the splenic artery and hepato-mesenteric trunk independently arising from the abdominal aorta

This report describes a rare case of an arterial anomaly in the celiaco-mesenteric region, encountered in a Japanese female cadaver for dissection at the gross anatomy laboratory of Kurume University School of Medicine in 2003. The usual celiac trunk was not identified, and the left gastric artery, the splenic artery and the hepato-mesenteric trunk independently arose from the abdominal aorta. Moreover, the hepatic artery arising from the hepato-mesenteric trunk ran behind the portal vein. The classification for this type of arterial anomaly is a Type II' of Morita's classification and Type II of Higashi and Hirai's classification, not belong to the Adachi's.

The clinical relevance of coeliac trunk variations

The coeliac trunk is a surgically significant artery originating from the abdominal aorta and supplying the supracolic organs. Branches of this arterial trunk supply the primary organs of the abdomen and divert a significant volume of blood from the abdominal aorta. Past research has shown that the anatomy of the coeliac trunk is not identical for all human beings and that about 15% of the population displays significant variations from the typical branching pattern. Data derived from earlier research has been consolidated to give an account of the major variations found in the anatomy of the coeliac trunk and to put forward some theories for the cause of such variation. It is crucial to achieve full comprehension of these topics as knowledge of these variations is indispensable in operative and diagnostic procedures within the abdomen. Without understanding of the arterial architecture and knowledge of the variation characterising the patient in this critical region surgery may entail a considerable risk of an error being committed that may occasionally lead to lethal complications.

The morphogenesis of the exstrophy-epispadias complex: a new concept based on observations made in early embryonic cases of cloacal exstrophy

BACKGROUND

The term exstrophy-epispadias complex (EEC) has been coined for a group of congenital malformations that includes epispadias, bladder exstrophy and cloacal exstrophy. It is usually thought that these malformations develop against a similar embryological background. This background, however, is still obscure. This is mainly due to the lack of availability of abnormal human or non-human embryos showing the crucial developmental steps in the morphogenesis of EEC malformations. In this paper, we present chick embryos that show cloacal exstrophy at early developmental stages. To the best of our knowledge, this is the first documentation of this rare malformation in young embryos.

MATERIALS AND METHODS

Embryos with cloacal exstrophy (n=4) were found among embryos from two experimental series (n=50) that were primarily performed to document the early morphogenesis of facial and cardiovascular malformations. The malformations were induced by the administration of suramin according to established protocols. Suramin can induce a spectrum of malformations including facial clefts, heart defects, and cloacal exstrophy.

RESULTS AND CONCLUSIONS

Besides the presence of an abnormal opening into the cloaca, all embryos were characterised by an abnormal broadening of the caudal trunk at the level of the leg buds, which, in the youngest embryos, was associated with the abnormal presence of large aneurysmatic swellings of the dorsal aortae at this side. We postulate that these aneurysmatic swellings might be the primary defects leading to the development of EEC malformations. These space-occupying anomalies seem to cause abnormal distensions of the developing pelvis and of the infra-umbilical portion of the developing body wall. In consequence, the mid-portion of the developing ventral body wall between the origin of the umbilical cord and the cloacal plate becomes stretched and thinned out. Tension and thinning of the ventral body wall might ultimately lead to its rupture with exposure of the lumen of the embryonic cloaca and allantois. This new concept on the morphogenesis of the EEC is the first not to be inferred from the conditions seen in fetal or postnatal human cases but is based entirely on data from malformed embryos.

[Hypoplasia of the descending thoracic and abdominal aorta in Williams-Beuren syndrome]

Hypoplasia of the descending thoracic and abdominal aorta is a very rare condition and its etiology is poorly understood. Associations with congenital and acquired disorders have been reported. In this article we present the case of a 24-year-old woman with hypoplasia of the thoracic and abdominal aorta and Williams-Beurensyndrome. This rare syndrome is attributed to deletions of genes on chromosome 7, among other the elastin-gene, and is characterized by cardiovascular anomalies, dysmorph facial features and mental retardation. The patient presented with a history of severe hypertension and recurrent abdominal pain since childhood. Diagnosis was established by duplex-sonography and magnetic resonance angiography. The patient was treated by an aortoaortic bypass from the ascending to the infrarenal aorta with reinsertion of the visceral and the right renal arteries. It is essential to recognize the condition early to withhold high morbidity and mortality resulting from long standing severe hypertension.

[Unusual association of chylopericardium and aortic hypoplasia in a neonate]

We report the case of a neonate with two very rare anomalies: primary chylopericardium and diffuse hypoplasia of the thoraco-abdominal aorta. The presentation on the 16th post-natal day was with dyspnoea and refusal to feed. The initial clinical examination revealed hepatomegaly and weak femoral pulses. 2D ultrasound gave a diagnosis of a large compressive pericardial effusion combined with moderate hypoplasia of the aortic isthmus. Emergency pericardial drainage removed 80ml of chylous liquid. Following prolonged parenteral nutrition, the pericardial effusion stabilised. A mechanism of diffuse vascular disease affecting the aorta and the lymphatic system is suggested.

Thoracoabdominal coarctation of the aorta

Atypical coarctation of the lower descending or the abdominal aorta is a relatively rare disease which occurs in about 0.5 to 2% of all coarctation cases. The majority of these diseases present with circumscribed narrowing of the abdominal aorta. However, we treated a 7-year-old boy with a rare form: a long, diffuse hypoplasia of the thoracoabdominal aorta.

Embolization of the Systemic Arterial Supply via a Detachable Silicon Balloon in a Child with Scimitar Syndrome

Scimitar syndrome is a rare congenital disorder. It is characterized by partial or total abnormal venous drainage of the right lung into the inferior vena cava, which is often associated with anomalous systemic arterial supply to the right lung, congenital cardiac anomalies, hypoplasia of the right lung and bronchial anomalies. Symptoms depend on the degree of the shunt and severity of the associated anomalies, which determine the treatment. We present a 6-year-old boy who was diagnosed as having the adult form of scimitar syndrome during evaluation for recurrent pulmonary infections, and underwent embolization with a detachable silicon balloon of the anomalous systemic arterial supply from the abdominal aorta to the right lower lung lobe. Successful elective surgery was performed 6 months later, in which right pulmonary veins were directed to the left atrium using a Gore-Tex patch by creating an intra-atrial tunnel. The patient has been symptom-free period during 6 months of follow-up, which supports the idea that recurrent pulmonary infections can be eliminated by embolization of the anomalous arterial supply.

[The aortocaval fistula, a rare complication of an aneurysm of the abdominal aorta]

Four patients, 3 men aged 73, 60 and 81 years with hemodynamic instability and 1 man aged 80 with abdominal symptoms and breathlessness appeared to have an arteriovenous fistula secondary to spontaneous rupture of an atherosclerotic aneurysm: between the aorta and the V. cava inferior or between the A. and the left V. iliaca communis. One patient died, one patient had postoperative decompensatio cordis, one suffered a deep vein thrombosis and the 4th recovered without symptoms. The presence of an aortocaval fistula has to be considered in patients with a symptomatic abdominal aneurysm with a harsh bruit heard over the abdomen, signs of high venous pressure and peripheral hypoperfusion. When no rupture of the aneurysm is found at laparotomy in symptomatic patients, the presence of a fistula is rare, but has to be considered. Furthermore, a fistula can be the underlying cause of therapy-resistant heart failure or acute renal dysfunction. Pre-operative identification can lead to decrease of morbidity and mortality of the phenomenon.

Abdominal aortic aneurysm with aortocaval fistula and a separate retroperitoneal rupture

The occurrence of an aortocaval fistula (ACF) secondary to an abdominal aortic aneurysm (AAA) is uncommon and is often undiagnosed prior to AAA repair. Clinical signs may be subtle or absent; therefore, diagnosis requires a high suspicion and knowledge of this phenomenon. We present a case of the rarest form of ACF (type 4) in which an AAA and an occult ACF were associated with a second site of retroperitoneal rupture. The ruptured AAA and ACF were successfully managed with fistula ligation and aortic graft placement.