Transcatheter Closure of Aortocaval Fistula With the Amplatzer Duct Occluder

PURPOSE

To report percutaneous closure of aortocaval fistulas with the Amplatzer Duct Occluder.

CASE REPORTS

An aortocaval fistula was diagnosed after surgical repair of an abdominal aortic aneurysm in a 73-year-old man. A 3-year-old girl was treated for a congenital aortocaval fistula in another case. An 8 x 6-mm Amplatzer Duct Occluder was introduced via a 6-F introducer in each case, successfully occluding the fistulous track. Both patients are well and without any echocardiographic evidence of a shunt at 6 months.

CONCLUSIONS

In selected patients, transcatheter closure of aortocaval fistula with the Amplatzer Duct Occluder could be an alternative to open surgery. Further evaluation is necessary.

[Congenital malformations of the abdominal aorta]

Thirty-four patients with a congenital malformation of the abdominal aorta were observed from 1970 to 2002. Thirty-two patients had associated lesions of the renal artery (ies) and 13 had lesions of the splanchnic arteries. Arterial hypertension was present in 32 patients, and two patients had intermittent claudication in the lower limbs. Two sudden deaths occurred before surgery was undertaken. The 32 other patients were operated on. Aortic bypass was performed in 10 patients. The lesions of the renal artery (47 kidneys at risk) were treated by nephrectomy in two cases and vascular repair in 45 cases. Six reconstructions of the superior mesenteric artery were carried out during the same procedure. There were no postoperative deaths. After surgery, arterial hypertension was cured in 74% of the patients, improved in 23% and unchanged in 3%. The intermittent claudication disappeared after aortic bypass in the two patients concerned. In four patients, deterioration of the renal artery repair led to repeat surgery. All aortic reconstructions remained patent, and no late anatomic deterioration occurred. Surgical treatment of renal artery lesions is necessary in most patients. Aortic repair should be reserved for tight stenoses and should be done as close as possible to the end of the growth phase.

[Hypoplasias of the thoracic and abdominal aorta: presentation of two cases, with evaluation 11 and 20 years after surgical management]

Two cases of hypoplasia of the thoracic and abdominal aorta are reported, diagnosed in two individuals, a girl 13 years old and a boy aged 16 years. The malformation involved the upper abdominal aorta and the visceral arteries in the first case, and simply the descending thoracic aorta in the remainder. Arterial hypertension was the principal manifestation who lead to the diagnosis, which was confirmed through the conventional angiography. Both patients underwent surgical management, which consisted in the aortic revascularization associated to complete visceral revascularization in the first case, and in the single aortic revascularization in the second patient. Surgical therapy course was uneventful in both cases and blood pressure returned to normal values following the operation. Reviewed 11 and 20 years after the procedure, they were found in good condition, with normal blood pressure without any medication; angio CT studies disclosed the prosthetic grafts working in excellent condition. The main features of etiopathogeny, clinical presentation, diagnosis and surgical management are subjected to a discussion, based on an extensive review of the literature dedicated to this clinical entity.

Spontaneous aortocaval fistula presenting with acute liver and renal failure: a case report

Spontaneous aortocaval fistula is rare, occurring only in 3%-6% of all ruptured abdominal aortic aneurysms. A definitive diagnosis of aortocaval fistula is sometimes difficult, as the classic diagnostic signs (pulsatile abdominal mass with bruit, high-output heart failure and acute dyspnea) are present only in 20%-50% of all such cases. Pre-operative diagnosis is crucial, as adequate preparation has to be made for the massive bleeding expected at operation. Surgical repair of aortocaval fistula is now standardized repair of the fistula. We report herein a case of spontaneous aortocaval fistula, which presented with liver and renal failure.

Severe hypoplasia of the abdominal aorta and its branches in a patient and his daughter

We report the history of a patient and his daughter, both affected with hypoplasia of the abdominal aorta and its branches, leading to early and dramatic complications. In the index patient, renal ischaemia as a result of severe hypoplasia of the abdominal aorta and the origin of renal arteries led to progressive renal failure and end-stage renal disease at the age of 32 years. Other vascular abnormalities included hypoplasia of the celiac trunk (CT) and superior mesenteric artery (SMA). After a successful kidney transplantation at the age of 40 years, he eventually deceased following an episode of possibly ischaemic acute pancreatitis at 47 years. The patient's daughter suffered from an haemorrhagic stroke at the age of 7 years, which led to the discovery of severe hypertension caused by bilateral narrowing of renal arteries, as well as hypoplasia of CT, SMA, subclavian and pulmonary arteries. Biopsy of the narrowed renal artery of the daughter showed a particular form of fibrodysplasia characterized by an unusual fibrosis of the inner part of the media, just beneath the internal elastic lamina. To our knowledge, this is the first report of familial hypoplasia of the abdominal aorta. It might be the cardinal manifestation of a familial form of fibromuscular dysplasia (FMD). Interestingly, the histological lesions described in the daughter's renal artery differ from the classical form of medial FMD.

Pivotal role of the sub-supracardinal anastomosis in the development and course of the left renal vein

A retroaortic left renal vein is encountered frequently in the dissecting room and in radiological investigations. A number of recent reports of this variation led us to review the development of the renal veins and the inferior vena cava to understand its etiology. For further insight, we also examined our collection of serial sections of cat embryos. In human embryos of about 15 mm the "renal collar," a venous ring around the aorta, is formed by anastomoses between subcardinal and supracardinal veins. The ventral part of the "renal collar" is formed from the intersubcardinal anastomosis, the dorsal part from the intersupracardinal anastomosis and the lateral parts from the sub-supracardinal anastomoses. The primitive renal veins drain venous blood from the metanephros into the sub-supracardinal anastomoses. A retroaortic left renal vein would form if the dorsal part of the sub-supracardinal anastomosis and the intersupracardinal anastomosis persist whereas the ventral part of the sub-supracardinal anastomosis and the intersubcardinal anastomosis regress.

Midaortic syndrome and subarachnoid hemorrhage associated with ruptured middle cerebral artery aneurysm: case report and review of the literature

OBJECTIVE AND IMPORTANCE

We describe the presentation, screening, management, and clinical outcome of a 21-year-old man who sought care for a ruptured middle cerebral artery (MCA) aneurysm and midaortic syndrome (MAS). Only three cases of MAS and intracranial aneurysm rupture have previously been described in the literature.

CLINICAL PRESENTATION

Cranial computed tomographic (CT) scanning, cerebral and abdominal angiography, and multislice three-dimensional CT angiography were used to evaluate intracerebral hemorrhage and to assess medically intractable hypertension in the patient. Digital subtraction angiography revealed a right MCA aneurysm, and multislice three-dimensional CT angiography revealed narrowing of the abdominal aorta.

INTERVENTION

The patient's right MCA aneurysm was successfully clipped via a right pterional craniotomy. A narrowed abdominal aorta was confirmed by an abdominal aortic angiogram (performed at Day 5 after surgery) and then dilated by using percutaneous transcatheter angioplasty during the same session. The patient was normotensive even without antihypertensive medications. Neurological examination and postoperative cranial CT findings were within normal limits at the last follow-up examination, performed 4 months after the operation.

CONCLUSION

Our patient is the first reported case of ruptured MCA aneurysm with MAS in an adult. The most important problem in the management of MAS associated with ruptured intracranial aneurysm is medically intractable hypertension, which may markedly increase the incidence of rebleeding. It is hard to achieve normotension unless the narrowed aorta and its branches are dilated. For these reasons, MAS should be considered in patients with medically intractable hypertension associated with ruptured intracranial aneurysm.

The lesser of two evils: a contextual view of the English case of the conjoined twins

In 2000 conjoined twin girls were born in Manchester, England. They were joined in such a way that it was impossible to separate them to enable both twins to survive. Their bodies were fused at the lower abdomen and they shared an aorta and a bladder. Their arms and legs were at right angles to their conjoined trunk. The situation of the conjoined twins is of supreme importance as a private tragedy for their family. The resulting litigation also presents an important landmark in English law. In deciding the fate of the two children, the Court of Appeal provided an authoritative review, analysis and application of family law and medical law with regard to neonates. The most significant legal legacy of the case, however, may well be in the field of criminal law by way of the court's interpretation and application of the defences of necessity and self-defence.

Multiple variations of abdominal vessels in a single cadaver

Variations of abdominal vessels are common and there are many reports about this subject. We report numerous variations of the superior part of the abdominal aorta and renal vessels which were determined in a single cadaver.

[Hematuria caused by nutcracker syndrome: peroperative confirmation of its presence]

Nutcracker syndrome should be considered in the case of left ureteric haematuria based on computed tomography with vascular reconstruction of the hilar region of the kidney. The best confirmation is obtained by studying the pressure gradient between the left renal vein and the inferior vena cava during cavography. Various modalities of surgical treatment have been proposed by a few authors, but have been criticised by some authors who question the clinical reality of this syndrome and the efficacy of treatment. The decision to operate may be difficult and other investigations may be useful to confirm the diagnosis. We report the case of a patient in whom the diagnosis of nutcracker syndrome was confirmed intraoperatively by the immediate appearance of massive, reversible haematuria induced by clamping of the renal vein during vein dissection and augmentation plasty. In the light of this original case, we believe that a preoperative percutaneous haematuria provocation test by temporary obstruction of the left renal vein during venography could allow a more formal diagnosis of nutcracker syndrome when this syndrome is highly suspected.

Jagged1 gene mutation for abdominal coarctation of the aorta in Alagille syndrome

Congenital cardiac defects such as peripheral pulmonary stenosis are well described in Alagille syndrome (AGS), which is transmitted in an autosomal dominant inheritance. Haploinsufficiency of the Jagged1 (JAG1) gene has been shown to cause AGS. Abdominal coarctation is an uncommon vascular congenital anomaly which has been described only three times in AGS. Recently, expression of the Jagged1 gene has been found in the developing heart and in multiple associated vascular structures, including the descending aorta. Mutation analysis of the Jagged1 gene in this fourth reported patient with coarctation of the abdominal aorta in AGS and right subclavian stenosis identified a mutation deletion (1485 Del CT). This agrees with the Jagged1 expression studies and suggests that coarctation of aorta may be a component of AGS.

Anomalies of the abdominal aorta in Williams-Beuren syndrome--another cause of arterial hypertension

Vascular disease in Williams-Beuren syndrome is based on an elastin arteriopathy which may cause stenoses in small and great vessels. This study presents the pattern of stenotic lesions of the abdominal aorta and the incidence of arterial hypertension. From 112 patients with Williams-Beuren syndrome followed since 1975, 25 patients were studied by aortography. The diameter of the thoracic aorta and the change in diameter to the iliac bifurcation were compared with normal data. Renal artery stenosis was suspected when the proximal vessel diameter was less than 50% of the distal diameter. Of the 25 patients, 20 had vascular stenosis of whom 19 patients were affected by segmental narrowing either of the thoracic aorta (n=9) or the abdominal aorta (n = 7) or both (n = 3). Hypoplasia of the abdominal aorta was characterised by the smallest diameters at the renal artery level and an increased diameter of the infrarenal abdominal aorta. A total of 11 patients had renal arterial stenosis, associated with narrowing of other aortic segments in 10 cases. Only one patient had a solitary stenosis of the renal artery. Arterial hypertension was diagnosed in 17 patients, 2 of them had no vascular lesions; in the remaining 15 patients stenosis was present in more than one segment (aorta 6, renal artery stenosis 1, both 8).

CONCLUSION

Narrowing of the abdominal aorta in patients with Williams-Beuren syndrome is a frequent morphological manifestation of the arteriopathy. Isolated renal arterial stenosis was rare, since it was more frequently combined with a narrowed aorta. Hypertension is a common symptom in the affected group and must be regarded as a manifestation of generalised arteriopathy rather than renal hypoperfusion.

Incidence of major venous and renal anomalies relevant to aortoiliac surgery as demonstrated by computed tomography

Preoperative knowledge of the presence of major venous anomalies facilitates the safe performance of aortic surgery. The purpose of the study was to estimate the incidence, as detected by abdominal and pelvic computed tomography (CT), of major venous and renal anomalies related to the abdominal aorta in an adult population. A total of 1822 intravenous contrast-enhanced abdominal and pelvic CT scans done in 1822 patients at two university teaching hospitals were randomly selected and prospectively reviewed (between June 1999 and March 2000) to identify major venous and renal anomalies associated with the abdominal aorta and iliac arteries. An interpreting staff radiologist then indicated on adata sheet whether any of the following anomalies were present or absent: (1) retroaortic left renal vein, (2) circumaortic left renal vein, (3) left-sided inferior vena cava (IVC) without situs inversus, (4) left-sided IVC with situs inversus, (5) duplicate IVC, (6) preaortic confluence of the iliac veins, or (7) horseshoe kidney. The CT scans reviewed had been performed for a wide variety of indications. Thirty-four scans were excluded from the study because either the anomalies we were looking for could not be assessed for technical reasons or the patient had a previous left nephrectomy and therefore assessment of the left renal vein was impossible. From this analysis we found that in an adult population, the prevalence of major venous and renal anomalies related to the abdominal aortaand iliac arteries and detected by CT scan was 5.65%. Prior to aortic surgery, preoperative knowledge of the presence of such anomalies helps with operative planning and may reduce the risk of major venous hemorrhage associated with these anomalies.

[Preoperative arterial embolization of intralobar lung sequestration]

A case of a 43-year-old patient with recurrent pulmonary infections due to pulmonary sequestration is presented. MR-angiography revealed an aberrant artery originating from the abdominal aorta feeding the intralobar pulmonary sequestration. Platinum coil embolization of the aberrant artery was performed preoperatively to allow safe surgical resection on the following day. To our knowledge this is the first case in the literature in which elective coil embolization has been performed before resection of lung sequestration.

A sword for the left hand: an unusual case of left-sided scimitar syndrome

Scimitar syndrome is a rare anomaly involving abnormalities of the heart and lung which classically involves the right side. A rare case of left-sided scimitar syndrome is described in an asymptomatic child, with a review of the literature.

Small aorta syndrome: hypothesis or reality?

A syndrome of peripheral obliterating arterial disease characterised by aortoiliac steno-occlusion is reported in the literature under the name small aorta syndrome, occurring in young women of small stature with relatively typical risk factors. Starting from an analysis of the studies reported in the literature and on the basis of our own results, we have attempted to ascertain whether small aorta syndrome represents an independent nosological entity. By analysing studies on the small aorta syndrome and in the light of a recent study made by our group on arterial diameters measured in cadavers, which highlights a significant correlation between aortic diameter and age, it can be affirmed that a pathology of this nature does not respond to absolute criteria for existence. Therefore, the aortoiliac diameter in women suspected of being affected by small aorta syndrome appears to be broadly in proportion to that expected in healthy women of the same age. Small aorta syndrome does not therefore appear to represent a separate nosological entity. It takes the form of a hypoplastic vascular disorder, which is probably congenital, correlated to other arterial districts in the same subject. However, it may encourage the onset of early symptoms in women of small stature.