Pathology of the diffuse variant of supravalvar aortic stenosis

Supravalvar aortic stenosis is a rare congenital heart anomaly, producing left ventricular outflow tract obstruction. Of the two anatomic variants that have been described, diffuse type is the rarest. We report five such cases in children between two months and nine years of age. None had features of Williams syndrome. The entire aorta was involved in three cases, with abdominal aortic coarctation in two cases. Stenosis was mainly due to involvement of the media, which showed smooth muscle hypertrophy, abnormal elastic fibers, and mild collagenization. Predominant intimal change was seen in one case. Pulmonary, coronary, arch, renal, and common iliac arteries were also involved.

An anomalous case of the hepato-spleno-mesenteric and the gastro-phrenic trunks independently arising from the abdominal aorta

This report describes an arterial anomaly case in the celiaco-mesenteric region, which was encountered in a Japanese male cadaver in the dissecting room at Kurume University School of Medicine in 1999. In this case, the usual celiac trunk was not identified, and the hepato-spleno-mesenteric and the gastro-phrenic trunks were independently arising from the abdominal aorta. In addition, the common hepatic artery divided into the left hepatic, the right hepatic, and the gastroduodenal arteries simultaneously, then, the accessory gastric artery arose from the left hepatic artery. This type of arteral anomaly belongs to the Type III of Adachi's classification and the Type II of Morita's classification.

Multiple arterial anomalies in the newborn infant. Echocardiographic and angiographic diagnosis

Multiple arterial anomalies characterized by tortuosity and rolling of the pulmonary arteries and aorta were diagnosed on echocardiography in an asymptomatic newborn infant with a phenotype suggesting Ehlers-Danlos syndrome. These changes were later confirmed on angiography, which also showed peripheral vascular abnormalities. The electrocardiogram showed a probable hemiblock of the left anterosuperior branch, and the chest x-ray showed an excavated pulmonary trunk with normal pulmonary flow.

[The double aorta--rarity or artifact of ultrasound]

The double aorta is very rare. Only two cases are described in the literature. More frequent is a duplication artifact which is misinterpreted as being the image of a double aorta. This is caused by a refraction artifact which results from the difference in the velocity of sound between muscle tissue and fat tissue. Furthermore, a fat depot between parts of the rectus abdominis muscle has a prism-like effect. In most cases, this artifact can be avoided by lateral shifting of the transducer.

Simultaneous coronary artery bypass grafting and ascending aorta bifemoral bypass in small aorta syndrome

A 55-year-old man with severe coronary artery disease and aortoiliac occlusive disease with small aorta syndrome was admitted to our department with angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery with a markedly hypoplastic infrarenal aorta only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in-situ right internal mammary artery graft, an autologous saphenous vein graft, and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and bifemoral arteries were patient. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease, especially in those with small aorta syndrome.

Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings

Congenital anomalies of the inferior vena cava (IVC) and its tributaries have become more commonly recognized in asymptomatic patients. The embryogenesis of the IVC is a complex process involving the formation of several anastomoses between three paired embryonic veins. The result is numerous variations in the basic venous plan of the abdomen and pelvis. A left IVC typically ends at the left renal vein, which crosses anterior to the aorta to form a normal right-sided prerenal IVC. In double IVC, the left IVC typically ends at the left renal vein, which crosses anterior to the aorta to join the right IVC. In azygos continuation of the IVC, the prerenal IVC passes posterior to the diaphragmatic crura to enter the thorax as the azygos vein. In circumaortic left renal vein, one left renal vein crosses anterior to the aorta and another crosses posterior to the aorta. In retroaortic left renal vein, the left renal vein passes posterior to the aorta. In circumcaval ureter, the proximal ureter courses posterior to the IVC. Other anomalies include absence of the infrarenal IVC or the entire IVC. These anomalies can have significant clinical implications. Awareness of these anomalies is necessary to avoid diagnostic pitfalls.

Two patients with varying combinations of sternal cleft, haemangiomas, midline abdominal raphe, coarctation of the aorta with a right aortic arch

We report two patients, one with sternal cleft, haemangiomas, supraumbilical midline raphe and the other with a sternal cleft, haemangiomas, coarctation of the aorta with a right aortic arch.

Spontaneous elastic tissue lesions in the rat abdominal aorta, a genetically determined phenotype

In this study, phenotypic expression of spontaneous elastic laminae defects within the rat abdominal aorta was examined. Lesions in Brown Norway (BN) rats were compared with those of New Zealand genetically hypertensive (GH) rats. BN and GH rats were cross-bred to determine the phenotypic expression of these lesions in successive F(1) and F(2) generations. Lesions were assessed by distribution, number and a semiquantitative index of severity. All BN aortae contained numerous elastic tissue defects. In comparison, GH aortae contained only occasional elastic tissue lesions. F(1) aortae contained lesions in numbers similar to those of the parental BN strain; however, F(1) lesions were of significantly greater severity. Within the F(2) generation, a wide range in both lesion numbers and severity indices was observed, with approximately a quarter of animals having lesion numbers analogous to the GH parental strain. In conclusion, this study indicates that the spontaneous elastic tissue lesions observed within BN rats are consistent with an autosomal dominant, possibly single gene, effect. Moreover, epistatic effects, derived from the GH strain, may influence the severity of these lesions. The gene(s) responsible may be important in the development of conditions such as arteriosclerosis and aneurysms in humans.

Two anomalous cases of the hepato-mesenteric and the gastro-splenic trunks independently arising from the abdominal aorta

This report describes two arterial anomaly cases in the celiaco-mesenteric region, which were encountered in two Japanese male cadavers in the dissecting room at Kurume University School of Medicine in 1999. In these cases, the usual celiac trunks were not identified, and the hepato-mesenteric and the gastro-splenic trunks were independently arising from the abdominal aorta. Moreover, in the first case, the common hepatic artery passed ventral side of the portal vein and divided into the hepatic proper and the gastroduodenal arteries. This type of arterial anomaly belongs to the Type V of Adachi's classification and the Type IV' of Morita's classification. In the second case, the common hepatic artery passed dorsal side of the portal vein and divided into the hepatic proper and the gastroduodenal arteries. This type of arterial anomaly belongs to the Type VI of Adachi's classification and the Type IV' of Morita's classification.

An unusual peritoneal fossa: anatomic report and clinical implications

The peritoneal fossae are usually related to rotation and adhesion of the abdominal viscera to the posterior abdominal wall during fetal development, and/or the presence of retroperitoneal vessels running just under the peritoneum and raising serosal folds. These fossae, therefore, are regarded as congenital and have been considered clinically and surgically as sites of internal abdominal hernias. The authors describe a peritoneal fossa interposed between the fourth portion of the duodenum and the abdominal aorta. Due to a scoliosis of the lumbar column, the abdominal aorta had shifted to the left of the duodenum, stretching two semilunar avascular peritoneal folds connecting the vessel with the ascending duodenum. These two folds bounded above and below an entrance into a fossa lined by the posterior parietal peritoneum and bordered by the fourth portion of the duodenum on the right and the aorta on the left. This recess extended as far as the anterior surface of the second and third lumbar vertebrae. On the basis of the anatomic findings, the authors suggest that acquired fossae, because of their size and topography, may play a part in the etiopathogenesis of internal abdominal hernias.

Aorto-left renal vein fistula: is there a place for endovascular management?

PURPOSE

To describe the endovascular treatment of an aorto-left renal vein fistula.

METHODS AND RESULTS

A 77-year-old man with multiple comorbidities presented with low back pain, hematuria, cyanosis, and a pulsatile abdominal mass. Imaging confirmed a 7-cm abdominal aortic aneurysm with a contained rupture into the left renal vein. Owing to the patient's high surgical risk, a Talent Endoluminal Stent-Graft was implanted to satisfactorily exclude the aneurysm. Hemodynamic stability and normal renal function were restored; however, continued perfusion of the sac prompted an attempt to percutaneously repair the renal vein defect. This effort failed, so open laparotomy was necessary.

CONCLUSIONS

Although total endovascular management was not successful in this case, the initial use of a minimally invasive approach allowed the patient's clinical status to improve and lower the risk of subsequent surgery.

Left gastric artery originating directly from the aorta

During the dissection of a 48-year-old male cadaver, the left gastric artery was observed directly originating from the abdominal aorta. An unusual embryologic development of the ventral splanchnic arteries may lead to considerable variations. The rare occurrence of this variation is stated to be 0.5%-15%. This case of the left gastric artery is described in detail, especially its point of emergence which may be important in operative procedures on the supracolic organs, in stomach resection, and during dissection of lymph nodes along this artery in gastric cancer.

A variation of coeliac trunk

The anatomical variations of the coeliac trunk are due to developmental changes in the ventral splanchnic arteries. This report describes a case in which the left inferior phrenic artery and left gastric artery arose from the long coeliac trunk (4.3 cm.) via a common trunk. The arterial variations, like other anatomical variations, cannot be ignored during the operative procedures in abdomen. Therefore the different forms of variations concerning the coeliac trunk should be kept in mind during both surgical and non-surgical evaluations.

Gross hematuria of uncommon origin: the nutcracker syndrome

Left renal vein hypertension, also called "nutcracker phenomenon" or "nutcracker syndrome," is a rare vascular abnormality responsible for gross hematuria. The phenomenon is attributable to the idiopathic decrease in the angle between the aorta and the superior mesenteric artery with consequent compression of the left renal vein. The entrapment of the left renal vein is not easily detectable by ordinary diagnostic procedures. We report two cases of gross hematuria (persistent in one patient and recurrent in the other) caused by "nutcracker phenomenon." In both cases, no remarkable findings were obtained from medical history, urinary red blood cells morphology, repeated urinalysis, pyelography, cystoscopy, or ureteroscopy. Left renal vein dilation in one case was found with a computed tomography (CT) scan performed on the venous tree of left kidney. The diagnosis of "nutcracker phenomenon" was confirmed by renal venography with measurement of pressure gradient between left renal vein and inferior vena cava in both cases. In one case, the diagnosis was complicated by the presence of Mycobacterium tuberculosis in urine. The "nutcracker phenomenon" is probably more common than thought. Early diagnosis is important to avoid unnecessary diagnostic procedures and complications such as the thrombosis of the left renal vein. Many procedures are available to correct the compression of the left renal vein entrapped between the aorta and the superior mesenteric artery: Gortex graft vein interposition, nephropexy, stenting, and kidney autotransplantation. After surgery, gross hematuria ceases in almost all patients.

Coarctations of descending and abdominal aorta: long-term results of surgical therapy

PURPOSE

Nonarteriosclerotic and nonarteritic descending and abdominal aortic coarctation (DAAC) is a rare disease with a great variety of morphologic findings. The additional affliction of renal and other splanchnic arteries often affords complex corrective procedures. We report on our single-center long-term experiences with operative treatment of this malformation.

METHODS

Over a period of 21 years, 15 patients (10 female and 5 male patients; age range, 8 to 57 years) were operated on for DAAC. Six patients had additional stenoses of eight renal arteries, and three had splanchnic arterial obstructions. At 4 to 25 years after the operation, all surviving patients underwent a clinical and a spiral computed tomography examination.

RESULTS

There was one intraoperative death due to exsanguination after the rupture of a poststenotic aneurysm of the infrarenal aorta. Fourteen patients were discharged free of symptoms. During follow-up, four repeated operations were necessary for renal arterial bypass stenoses or aneurysms. One late death occurred as the result of an unrelated disease.

CONCLUSIONS

Complete operative correction of DAAC usually can be accomplished as a single-stage procedure with low morbidity and mortality rates. The reconstruction of all renal arteries is essential to cure hypertension. Consequent follow-up is recommended for detection of late postoperative complications.

Congenital aorto-caval fistula in the newborn: a case report

The authors report a rare case of congenital fistula between the distal aspect of the descending aorta and the inferior vena cava. The clinical features of this aortocaval fistula is being described as well as the preoperative diagnostic workup, the intraoperative findings, and the complicated postoperative course and treatment.