Surgical Treatment of Middle Aortic Syndrome with Takayasu Arteritis or Midaortic Dysplastic Syndrome

Identification and treatment of midaortic syndrome in an adult patient with orthostatic tachycardia and hypertension: A case report

Anatomical cardiovascular etiologies are less frequently investigated and identified in cases of orthostatic intolerance, which can have a profound impact on a patient's functional status. Here, we present a 26-year-old female with a recent diagnosis of hyperadrenergic postural orthostatic tachycardia and hypertension who was found to have diminished pedal pulses. Workup revealed an underlying midaortic syndrome that was then surgically corrected with resolution of symptoms. We discuss the epidemiology, presentation, and management of this rare condition, as well as its role in our patient's symptomatology.

Long-term outcomes of surgical or endovascular treatment of adult with midaortic syndrome: A single-center retrospective study over a 14-year period

Objective

Midaortic syndrome is a rare clinical condition that has been mainly studied in juveniles through case reports and series. This study aims to report the anatomic characteristics and long-term outcomes of 41 adult patients with midaortic syndrome who received open surgical treatment or endovascular treatment over a 14-year period.

Methods

A consecutive cohort of 41 adult patients diagnosed with midaortic syndrome at our center between January 2008 and November 2021 were enrolled in the study. Patients' baseline and anatomic characteristics were collected and analyzed. Primary follow-up outcomes included death and reintervention. Other follow-up outcomes included hypertension and complications.

Results

The study enrolled 41 adult patients with midaortic syndrome with a mean age of 37.5 ± 13.4 years. Twenty-five patients received open surgical treatment, and 16 patients received endovascular treatment. Isolated infrarenal lesions were more likely to be found in the endovascular treatment group (P = .005), whereas patients with multiple (P = .002) or intravisceral involvement (P = .001) were more likely to be found in the open surgical treatment group. The open surgical treatment group was more likely to have a lower postoperative peak systolic pressure gradient (P = .020). The 5- and 10-year reintervention-free survivals were 87.7% and 71.7% in the open surgical treatment group and 92.3% and 79.1% in the endovascular treatment group, respectively.

Conclusions

Both open surgical treatment and endovascular treatment showed satisfactory long-term efficacy outcomes for adult patients with midaortic syndrome. Given the patients' relatively young age and long life expectancy, strict and regular lifelong follow-up is necessary.

Mini-access ascending aorto-bifemoral bypass surgery for the treatment of aortic steno-occlusive disease

Objectives

Mid-aortic syndrome is a rare condition characterized by severe aortic narrowing, leading to high upper body blood pressure and organ hypoperfusion, necessitating surgical intervention. Although central bypassing is considered ideal, it involves extensive incisions. To overcome these limitations, less-invasive approaches have been developed. This study aims to introduce a mini-access approach using video-endoscopy and to evaluate the feasibility and outcomes of mini-access ascending aorto-bifemoral bypass surgery.

Methods

From November 2020 to May 2022, we performed ascending aorta to bifemoral artery bypass operations on 7 patients to treat steno-occlusive diseases in the downstream aorta. A Y-graft was created, and procedures were conducted under general anesthesia using video-endoscopy with limited skin incisions.

Results

Intraoperatively, there were no major complications, and none of the patients required cardiopulmonary bypass support. Furthermore, there were no postoperative mortalities or major complications. Postoperatively, the mean ankle-brachial index significantly improved from 0.59/0.59 to 0.96/0.92 (P = .004), and the mean glomerular filtration rate increased from 61.1 to 85.3 mL/min/1.73 mm2 (P = .012). Additionally, symptoms of claudication resolved in all patients.

Conclusions

Videoscope-assisted mini-access aortic bypass surgery not only provides favorable early postoperative outcomes but also represents a technically feasible alternative to traditional surgical approaches for the treatment of steno-occlusive aortic diseases.

Anesthetic Management of Middle Aortic Syndrome in an Adult: A Case Report

Middle aortic syndrome (MAS) is a rare disorder characterized by narrowing of the aorta. Depending on the location and extent of aortic narrowing, surgical management may be necessary to prevent long-term sequelae, such as stroke and congestive heart failure. We report a case of MAS and discuss the unique intraoperative anesthetic considerations including hemodynamic monitoring proximal and distal to the aortic narrowing, minimizing the risk of spinal cord ischemia, and utilization of intraoperative dobutamine stress testing to guide surgical management.

Operative experience on descending aorta with Takayasu Arteritis: a review

Patients with Takayasu arteritis (TA) and descending aorta involvement often experience insidious onset and slow progression, leading to irreversible vascular lesions despite medication therapy. Surgical management plays a crucial role in resolving hemodynamic disturbances and has shown promise in improving the outcomes of this patient population, owing to significant advancements in surgical expertise. However, studies focusing on this rare disease are lacking. This review summarizes the characteristics of patients with stenosis in descending aorta, emphasizing surgical approaches, perioperative management, and disease outcomes. The operative approach depends on lesion location and extent. Existing studies have confirmed that the choice of surgical modality significantly influences postoperative complications and long-term prognosis in patients, highlighting the effectiveness of bypass surgery as a favorable option in clinical practice with a satisfactory long-term patency rate. To mitigate postoperative complications, it is advisable to conduct regular imaging follow-ups to prevent the deterioration of the condition. Notably, the occurrence of restenosis and pseudoaneurysm formation deserves particular attention due to their impact on patient survival. The use of perioperative medication remains a topic of debate, as previous studies have presented divergent perspectives. The primary objective of this review is to provide a comprehensive perspective on surgical treatment and offer customized surgical approaches for patients in this population.

A rare middle aortic syndrome with celiac trunk, superior mesenteric and bilateral renal artery involvement

Middle aortic syndrome (MAS) is a rare atypical aortic coarctation (AC), often accompanied by refractory renal hypertension, which eventually leads to death from congestive heart failure, stroke or hypertensive encephalopathy. Computed tomography angiography (CTA) has unique advantages in assessing aortic stenosis and splanchnic artery abnormalities. Prompt aortic bypass surgery can relieve symptoms and improve quality of life. In this study, we report a patient with MAS diagnosed by CTA and follow-up after thoracoabdominal aortic bypass grafting.

Successful Surgical and Endovascular Multidisciplinary Therapy for Mid-aortic Syndrome with Complicated Atherosclerotic Comorbidities in an Older Patient

Mid-aortic syndrome (MAS) is a rare vascular disorder that causes refractory hypertension. A 76-year-old woman was hospitalized for acute heart failure (HF) with drug-resistant hypertension; other comorbidities included epigastric artery rupture, old myocardial infarction, an intraventricular thrombus, and a cerebral artery aneurysm. Angiography revealed severe narrowing of the descending aorta, which led to the diagnosis of MAS. Although intensive medical treatment improved her HF, optimal blood pressure (BP) could not be achieved. Percutaneous coronary intervention and surgical bypass for diseased aorta was then performed in two stages, resulting in the achievement of optimal BP and alleviation of HF.

Surgical 5-year Outcomes of Extra-Anatomical Bypass for Middle Aortic Syndrome: A Case Series

BACKGROUND

Middle aortic syndrome is a rare disease. Several surgical treatments are available; however, the optimal treatment strategy and long-term outcomes remain unelucidated. We herein report the 5-year outcomes of six patients treated with extra-anatomical bypass surgery for middle aortic syndrome.

CASE PRESENTATIONS

Between 2013 and 2016, six patients underwent extra-anatomical bypass for middle aortic syndrome at our institute: three had Takayasu's arteritis, one had vessel vasculitis, and two had middle aortic hypoplastic syndrome of unknown origin. The patients included five women and one man, with a mean age of 59.7 years. Four patients had uncontrolled hypertension and were receiving antihypertensive medications. The mean ankle-brachial pressure index was .61. The three patients with Takayasu's arteritis were hospitalized for congestive heart failure. These patients underwent bypass surgery from the descending aorta to the infrarenal abdominal aorta, and one also underwent concomitant heart surgery. The patient with microscopic polyangiitis underwent Y-grafting with an aortic aneurysmectomy. Subsequently, bypass surgery was performed from the descending aorta to the graft via the diaphragm. The two patients with unknown causes underwent bypass surgery from the proximal descending aorta to the distal descending thoracic aorta. There were no early or late deaths at the 5-year follow-up. We did not observe any changes in anastomotic site stenosis or new aneurysmal changes during the follow-up period. The number of antihypertensive medications was reduced in all cases, and critical symptoms, including headache, severe abdominal pain, claudication, and heart failure, improved in all patients. The ankle-brachial pressure index increased to 1.11 and did not change for five years. Renal function remained stable, and the brain natriuretic peptide level decreased from 302.8 to 74.5 pg/mL at follow-up.

CONCLUSION

Extra-anatomical bypass for middle aortic syndrome is safe and effective, and can help prevent renal failure, and relieve critical ischemic symptoms.

Sequential numerical simulation of vascular remodeling and thrombosis in unconventional hybrid repair of ruptured middle aortic syndrome

Unconventional surgical procedures may be utilized in treating complicated middle aortic syndrome (MAS), the outcome and prognosis of which remain largely undetermined due to limited numbers and significant heterogeneity of this population. Using computational fluid dynamics (CFD) analysis, this study aimed to assess the dynamic changes of postoperative aortic flow in seeking to unveil the relationship between hemodynamics and vascular remodeling and thrombotic events. One patient with middle aortic syndrome complicated with aortic rupture was treated with hybrid repair of extra-anatomic bypass and fenestrated endovascular aortic repair. The patient was followed-up for 8 months by computational tomography angiography and Doppler ultrasound. Thoracoabdominal aortic blood flow and locations with ongoing thrombosis at 1, 3, and 6 months postoperatively were simulated and analyzed. Remodeling processes, including low wall shear-mediated constrictive remodeling of non-stented aorta, neointimal hyperplasia at suture lines, and minimal thrombosis at various locations, were evident. Meanwhile, abdominal blood flow was tri-phasic at 1 month after surgery, and was reversed and stabilized at 6 months. The distribution of newly formed thrombus vary at different follow-up stages, which were in line with the numerical simulation of thrombosis from different postoperative time points. CFD-based sequential monitoring is of promising value in capturing dynamic changes of vascular outcome.

Treatment of middle aortic syndrome with thoraco-abdominal aortic bypass grafting assisted by endoscope in adult

Middle aortic syndrome (MAS) is a rare disease characterized by distal thoracic aorta or abdominal aorta coarctation, and thoraco-abdominal aortic bypass grafting is an effective treatment for this condition. However, significant trauma is associated with the conventional surgical approach. We report a 26-year-old woman with MAS who presented with hypertension and needed thoraco-abdominal bypass grafting. In this operation, we adopted the endoscopic technique to improve the conventional surgical approach (reduce the incision). This case report shows that it is safe and feasible to use an endoscopic technique to reduce the trauma during this kind of operation, and provides a reference for similar treatments.

Clinical Scenario and Long-Term Outcome of Childhood Takayasu Arteritis Undergoing 121 Endovascular Interventions: A Large Cohort Over a Fifteen-Year Period

OBJECTIVE

Evidence-based studies on endovascular approaches for childhood Takayasu arteritis (TAK) are limited. Our objective was to present the largest current real-world scenario for patients with childhood TAK undergoing interventions and their postinterventional outcomes.

METHODS

Data were collected for patients with childhood TAK admitted from 2002 to 2017. Complication/reintervention-free survival was projected by Kaplan-Meier methods. Associated factors for intervention and predictors for postinterventional complications/reinterventions were assessed via regression models.

RESULTS

Among 101 patients enrolled, 69 (68.3%) underwent 121 interventions (angioplasty 95, stenting 26) during a 3.1-year follow-up. Compared with the nonintervention group, the intervention group independently associated with a male population (odds ratio [OR] 0.27, P = 0.035) and type IV disease (OR 17.92, P = 0.001). Male sex also marginally indicated a risk for reintervention (hazard ratio [HR] 3.22, P = 0.05). Baseline retinopathy, delay in diagnosis, and descending thoracic aorta involvement were associated with stent insertion (P < 0.05). Hypertension secondary to renal artery stenosis (RAS; 59.4%) or mid-aorta stenosis (MAS; 14.5%), heart failure (21.7%), and claudication (21.7%) were leading clinical hints for interventions. The technical success rate was 96.7%. During a median 2.88-year of follow-up after intervention, 36 lesions occurred with complications in 28 patients, and 22 lesions in 17 patients, particularly on the renal artery or mid-aorta. The 5-year complication-free and reintervention-free survivals were 50.7% and 65.8%, respectively. Peri-interventional dual antiplatelet therapy (DAPT; HR 0.31), concurrent surgery (HR 26.5), and technical failure (HR 3.65) were independent predictors for complications (P < 0.05). Male sex (HR 2.52), retinopathy secondary to hypertension (HR 3.41), and pulmonary artery hypertension (PAH; HR 3.64) were baseline indicators for complications (P < 0.05).

CONCLUSION

Over two-thirds of patients with childhood TAK require interventions, and the 5-year complication-free survival is 50.7%. Male sex, retinopathy, and PAH at baseline indicate the possibility of unfavorable outcomes. Interventions on MAS or RAS in childhood TAK raise specific concerns. DAPT peri-intervention appears to protect patients with childhood TAK from postinterventional complications.

Complex Aortic, Visceral and Renal Arteries Reconstruction with a Four-Branch Dacron Graft for Middle Aortic Syndrome Secondary to Takayasu's Arteritis

The middle aortic syndrome (MAS) is an uncommon clinical expression as a result of isolated stenosis or complete occlusion of the descending thoracic and/or abdominal aorta; Takayasu's arteritis (TA) is a rare vasculitis and a recognized etiology of MAS. We herein present the case of a 52-year-old woman with refractory renovascular hypertension and progressive bilateral lower extremity claudication; she had known history of TA. A computed tomography angiography demonstrated an aortic occlusive lesion compromising the origin of the celiac trunk, superior mesenteric, and bilateral renal arteries. The patient underwent a complex aortic reconstruction with visceral and renal vessels revascularization utilizing a back-table hand-crafted 4-branch Dacron graft through a left thoracoabdominal approach. The patient recovered uneventfully and was discharged on postoperative day 5, and at 36 months from her surgery, she remains symptoms-free and without antihypertensive agents.

Characteristics and Medium-term Outcomes of Takayasu Arteritis-related Renal Artery Stenosis: Analysis of a Large Chinese Cohort

OBJECTIVE

To investigate the characteristics of patients with Takayasu arteritis (TA)-related renal artery stenosis and identify the predictors of medium-term adverse outcomes.

METHODS

Data for 567 patients registered in the East China Takayasu arteritis cohort, a large prospective observational cohort, up to April 30, 2019, were retrospectively analyzed.

RESULTS

Renal artery stenosis was confirmed in 172/567 (30.34%) patients, with left renal artery involvement seen in 73/172 (42.44%) patients. Renal insufficiency at presentation (HR 2.37, 95% CI 1.76-15.83, P = 0.03), bilateral renal artery involvement (HR 6.95, 95% CI 1.18-21.55, P = 0.01), and severe stenosis (> 75%; HR 4.75, 95% CI 1.08-11.33, P = 0.05) were predictors of adverse outcomes. A matrix model constructed using 3 variables (renal function, stenosis severity, and bilateral renal artery involvement) could identify 3 risk groups. Revascularization was performed for 46 out of 172 (26.74%) patients. Patients without preoperative treatment had higher rate of restenosis (41.46% vs 16.67%, P < 0.01) and worsening hypertension (25.93% vs. 10.53%, P < 0.01) after the procedure. Nonreceipt of preoperative treatment (HR 6.5, 95% CI 1.77-32.98, P = 0.04) and active disease at revascularization (HR 4.21, 95% CI 2.01-21.44, P = 0.04) were independent predictors of adverse outcomes after revascularization.

CONCLUSION

Patients with TA-associated renal artery stenosis and uncontrolled or worsening hypertension or/and renal function may benefit from revascularization. Those who have received preoperative treatment may have more favorable revascularization outcomes. Prognosis appears to be poorer for patients with renal insufficiency at presentation, bilateral artery involvement, and severe stenosis.

Midaortic Syndrome due to Takayasu Arteritis in a Child with Acute Decompensated Cardiac Failure Managed by an Emergency Axillo-External Iliac Artery Bypass: A Follow-Up Case Report of Long-Term Outcomes

Midaortic syndrome (MAS) is characterized by a diffuse narrowing of the distal thoracic or abdominal aorta and is concomitant with various etiologies. The common symptoms of MAS include severe hypertension or arterial insufficiency distal to the stenosis. This includes lower extremity claudication and heart failure due to afterload mismatch. We present the case of an 8-year-old girl who developed acute decompensated cardiac, respiratory, and renal failures because of the occlusion of the descending aorta secondary to Takayasu arteritis (TA). Although thoracoabdominal-aortic bypass is usually performed for patients with MAS, the procedure was considered too invasive, given the patient's condition. Therefore, we performed an emergency axillo-external iliac artery bypass for revascularization. Subsequently, organ failure improved and she was discharged. At postoperative 10 years, an asymptomatic pseudoaneurysm was detected at the distal anastomosis, for which revision surgery was performed. Overall, the long-term prognosis was satisfactory, suggesting that this procedure is less invasive and effective for treatment of MAS due to TA, in emergencies.

Clinical Outcome of Extraanatomic Bypass for Midaortic Syndrome Caused by Takayasu Arteritis

BACKGROUND

We investigated long-term outcomes and cardiac function after extraanatomic bypass surgery for Takayasu arteritis and midaortic syndrome.

METHODS

Between 2007 and 2016, 14 patients underwent extraanatomic bypass for Takayasu arteritis. Median age was 56.6 years. Median systolic pressure gradient in the stenotic lesion was 79 mm Hg. Nine patients underwent bypass surgery from the ascending aorta to the infrarenal aorta, 2 from the ascending aorta to the distal descending thoracic aorta, 1 from the ascending aorta to the supraceliac abdominal aorta, 1 from the descending thoracic aorta to the infrarenal abdominal aorta, and 1 from the descending thoracic aorta to the descending thoracic aorta. Five underwent additional 6 peripheral bypass procedures, and 6 underwent concomitant heart surgery.

RESULTS

There were no early deaths. Median hospital stay was 10.5 days. Median follow-up duration was 36.3 months, and late death occurred in 2 patients. One died at 1 year postoperatively because of an infection due to pancreatic injury and mediastinitis. The other was lost to follow-up, and death was confirmed through the national insurance database. No anastomotic site stenosis or aneurysmal change occurred. The number of antihypertensive medications was reduced significantly in all but 1 patient, and organ ischemia symptoms, including dizziness, visual disturbance, and claudication, improved in all patients. Interventricular septal diameter and left ventricular mass index decreased significantly. Serum creatinine level also decreased. Overall estimated 5-year survival was 79% ± 13%.

CONCLUSIONS

Extraanatomic bypass for Takayasu arteritis is safe and effective and can be useful for left ventricular unloading and reduction of organ ischemia.

Severe midaortic syndrome: a stepwise approach to treatment with drug-eluting balloons: a case report

Background

Severe forms of the midaortic syndrome cause persistent arterial hypertension and can lead to angina abdominalis. Untreated, morbidity, and mortality are significant. In addition to palliation through bypass surgery, few other therapeutic approaches lead to a long-term relief. Drug-eluting balloons (DEB) covered with paclitaxel, a cytostatic drug, have proven to be effective in bifurcational lesions and for in-stent stenoses in coronary arteries.

Case summary

In a 15-year-old girl with severe midaortic syndrome and multiple collateral arteries, four interventional balloon dilatations with DEB of increasing diameters resolved the stenosis within 8 months. After a procedure free interval of now 2.7 years, the anatomical and the physical condition of the patient remained unchanged.

Discussion

This stepwise approach, with a low procedural risk and a lasting result may justify further investigations into this combined treatment.

Doppler ultrasonographic and clinical features of middle aortic syndrome

OBJECTIVES

To discuss Doppler ultrasonographic and clinical features of middle aortic syndrome (MAS).

MATERIALS AND METHODS

Doppler ultrasonographic images and clinical dates of 11 patients with MAS confirmed by angiography were retrospectively analyzed from January 2004 to September 2016.

RESULTS

The median age of 11 patients was 10 years (1-39 years). Ten patients presented with hypertension, only 2 cases presented with symptomatic intermittent claudication, and 1 case presented with abdominal pain. The ultrasonographic features of 11 patients with MAS included: (a) Gray-scale image showed significant segmental narrowing of the aorta in 9 cases. (b) Color Doppler demonstrated aliasing in the suspicious narrowed vessels of all cases. (c) On Spectral Doppler image, peak systolic velocity in the location of aorta coarctation was significantly elevated (range, 2.3~4.8 m/s). When infrarenal aorta was involved, a tardus-parvus waveform was only seen in the distal aorta. When suprarenal or inter-renal aorta was involved, a tardus-parvus pattern was seen in the distal aorta as well as renal artery.

CONCLUSIONS

Significant segmental narrowing and a tardus-parvus waveform are the important ultrasonographic features in patients with MAS, the latter may be more reliable. Doppler ultrasound can be used as a simple screening method, especially for children and adolescents suspected of having a vascular cause of refractory hypertension.

Endovascular Management of Middle Aortic Syndrome Presenting with Uncontrolled Hypertension

Middle Aortic Syndrome is a rare vascular disorder consisting of narrowing or stenosis of the distal thoracic or abdominal aorta. It is described in the literature in the form of case studies and case series. The authors present an unusual case of Middle Aortic Syndrome attributed to Takayasu's arteritis in a 60-year-old female who presented to the emergency department with uncontrolled hypertension. Traditional intervention involves open surgical bypass. This case study reviews the published literature on this rare syndrome and illustrates a successful alternative to open surgery through an endovascular approach.

The management of pediatric renovascular hypertension: a single center experience and review of the literature

INTRODUCTION

Renal artery occlusive disease is poorly characterized in children; treatments include medications, endovascular techniques, and surgery. We aimed to describe the course of renovascular hypertension (RVH), its treatments and outcomes.

METHODS

We performed literature review and retrospective review (1993-2014) of children with renovascular hypertension at our institution. Response to treatment was defined by National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents at most-recent follow-up.

RESULTS

We identified 39 patients with RVH. 54% (n=21) were male, with mean age of 6.93 ± 5.27 years. Most underwent endovascular treatment (n=17), with medication alone (n=12) and surgery (n=10) less commonly utilized. Endovascular treatment resulted in 18% cure, 65% improvement and 18% failure; surgery resulted in 30% cure, 50% improvement and 20% failure. Medication alone resulted in 0% cure, 75% improvement and 25% failure. 24% with endovascular treatment required secondary endovascular intervention; 18% required secondary surgery. 20% of patients who underwent initial surgery required reoperation for re-stenosis. Mean follow-up was 52.2 ± 58.4 months.

CONCLUSIONS

RVH treatment in children includes medications, surgical or endovascular approaches, with all resulting in combined 79% improvement in or cure rates. A multidisciplinary approach and individualized patient management are critical to optimize outcomes.

TYPE OF STUDY

Retrospective comparative study LEVEL OF EVIDENCE: Level III.

Colonic ischemia developed after laparoscopic colectomy for rectosigmoid cancer with focal infrarenal aortic stenosis

A 69-year-old woman with focal infrarenal aortic stenosis was diagnosed with rectosigmoid cancer. Because radical resection for colon cancer required dissection of vessels that supplied blood flow to the legs, revascularization by aortic stent placement was performed before the colectomy. We subsequently performed laparoscopic low anterior resection without any complications. Two and a half years after colectomy, however, the patient developed colonic ischemia due to thrombosis of the dilated marginal artery that served as a collateral artery before stenting. We performed laparoscopic partial colectomy, including the resection of the dilated marginal artery filled with thrombus. An abnormally dilated ex-collateral artery was thought to have caused vessel occlusion, presumably due to an imbalance in blood flow and vascular diameter.

Middle aortic syndrome with renal artery stenosis

A 39-year lady referred to Vascular Surgery OPD from Cardiology with uncontrolled hypertension, non- functional left kidney and absent bilateral femoral pulses. Investigations revealed middle aortic syndrome with non-functional left kidney with bilateral renal artery stenosis. She successfully underwent bypass of stenotic segment with polyester graft from descending thoracic aorta to left common iliac artery with reverse saphenous vein graft interposed between polyester and right renal artery.

Unlikely culprit: congenital middle aortic syndrome diagnosed in the sixth decade of life

A 58-year-old woman was admitted with acute heart failure. She had a long history of resistant hypertension, with an unremarkable work up for secondary causes in the past. Her brachial blood pressure was 210/70 mm Hg, with ankle blood pressure of 100/70 mm Hg. CT angiogram revealed marked narrowing of the descending thoracic aorta between the left subclavian artery and the diaphragm, consistent with middle aortic syndrome (MAS). She was initially managed with diuretics and antihypertensives. Subsequently thoracotomy revealed a severely hypoplastic segment of the descending aorta. The diseased segment was resected and aortic reconstruction performed. Histopathology showed fragmentation of the medial elastic fibres and fibrosis of the medial and intimal layers. These findings along with gross aortic hypoplasia and absence of features of Takayasu's arteritis, suggest that our patient had congenital MAS. The patient has done well since her surgery. We believe this is the first case of congenital MAS reported in the sixth decade of life.

Middle Aortic Syndrome in Takayasu's Arteritis: Report of Two Surgical Cases

An isolated stenotic or occluded segment of the descending thoracic and/or the abdominal aorta associated to Takayasu's arteritis (TA) is very uncommon and the clinical expression is known as "middle aortic syndrome." Manifestations depend on the lesion location, and may include hypertension originating from the aortic coarctation or renovascular, buttock, or lower extremity claudication and rarely chronic intestinal angina. We present 2 female patients with TA with occlusive lesions in the infrarenal aorta; both were treated with open surgical reconstruction of the affected segments. On follow-up, at 81 and 46 months, respectively, both patients remain symptoms free.