Disease Beyond the Arch: A Systematic Review of Middle Aortic Syndrome in Childhood

Mid-aortic syndrome presented as dilated cardiomyopathy

Mid-aortic syndrome (MAS) is a rare vascular disease that usually leads to renovascular hypertension. With the predominant manifestations being intractable arterial hypertension and lower extremity arterial insufficiency, it has rarely been associated with dilated cardiomyopathy. We report a young girl with congestive heart failure, where the cause was initially attributed to dilated cardiomyopathy. A repeated echocardiogram 6 months later brought the physician's suspicion of MAS because of the abnormal colour of Doppler from the subcostal view. Further assessment using CT angiography revealed discrete thoracic coarctation at the level of T10, with the narrowest diameter of 2.1 mm, thus confirming the diagnosis. Her inflammatory markers and connective tissue screening were negative. She underwent successful stenting of coarctation of the aorta, which later caused improvement in her cardiac function. We highlighted the importance of looking for treatable causes of dilated cardiomyopathy and vigilant clinical and echocardiogram assessment with high suspicion to diagnose MAS.

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.

A rare cause and an even rarer treatment of hypertension in a 5-year-old boy: Mid-aortic syndrome

Renal artery stenosis is one of the common vascular diseases that cause hypertension in children. However, renal artery aneurysms and abdominal aortic aneurysms, which may be components of mid-aortic syndrome, are rarely associated with renal artery stenosis. Despite its rarity, early diagnosis and treatment are critical to prevent fatal complications. Currently, non-surgical invasive techniques are considered the first choice for treatment, but in some cases, surgery is inevitable. Here, we present a 5-year-old boy with a mid-aortic syndrome. The patient presented with a history of severe headache and epistaxis 5-6 times a day and was diagnosed with hypertension. A 9 × 9 mm saccular aneurysm on the anterior surface of the abdominal aorta at the level of the left renal artery ostium, and a 12 mm aneurysm in the left renal artery after a stenotic segment at the hilum level was detected in the doppler USG and contrast-enhanced imaging techniques. The patient was operated on electively. We used a PTFE patch to repair the abdominal aorta and, saphenous vein which was taken from his father to repair the renal artery. The patient recovered well and was discharged on the 18th day.

Case report of a rare cause of secondary hypertension illustrating the importance of cardio-obstetric preconception counselling

Background

Cardiovascular diseases represent a leading cause of maternal morbidity and mortality in industrialized countries. High blood pressure during pregnancy is a major driver of short- and long-term cardiovascular health in both mother and child. Screening and adequate treatment of elevated blood pressure before pregnancy significantly reduce mortality risk to mother and child.

Case summary

A 30-year-old woman with middle aortic coarctation (MAC) previously treated with aortic stenting was referred to our cardio-obstetrics with plans to become pregnant. The clinical examination revealed severe hypertension with a significant blood pressure gradient between the upper and lower limbs. The patient underwent computed tomography angiography showing re-stenosis of the aorta. After the analysis of the benefit risk of all treatment options, percutaneous transluminal aortic in-stent re-stenting was performed. Following the intervention, blood pressure profile significantly improved but remained slightly elevated further necessitating the introduction of an antihypertensive therapy.

Discussion

This clinical case condenses several challenges encountered in the management of hypertension in women who plan to become pregnant. Firstly, it emphasizes the fact that secondary causes of chronic hypertension, including MAC, do not have to be overlooked in childbearing age patient. Secondly, it illustrates the need for a multidisciplinary analysis of all available treatment options in view of a future pregnancy. Finally, it discusses the particular follow-up and potential complications in pregnant women with MAC and aortic stent.

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.

Computed Tomography Measurement of the Aorta in Midaortic Syndrome in Children and Adolescents and Their Clinical Manifestations and Outcomes

Midaortic syndrome (MAS) presents challenges in diagnosis due to the absence of well-defined diagnostic criteria in pediatric patients. This retrospective study aimed to aid in the diagnosis of MAS by employing computed tomography (CT) to measure the z-score of the aorta as well as to identify and understand its clinical features. CT images, echocardiography findings, and medical records of 17 patients diagnosed with MAS between 1997 and 2023 were reviewed, and z-scores were calculated. Aortic size on follow-up CT, blood pressure, and left ventricular function and hypertrophy at the last follow-up were analyzed, and possible prognostic factors were examined. Except for one patient, all individuals exhibited a z-score below - 2 at the level corresponding to stenosis. Left ventricular dysfunction occurred more frequently in patients aged < 5 years (p = 0.024). Patients with idiopathic MAS showed a better prognosis in terms of blood pressure and follow-up aortic size (p = 0.051 and 0.048, respectively). CT-measured aortic z-scores may be useful for the diagnosis and follow-up of MAS.

Surgical Strategies and Long-Term Outcomes for Complex Coral Reef Aorta with Multisegmental Involvement: A Case Report

Coral reef aorta (CRA) is a rare condition characterized by the distribution of rock-hard calcifications in the visceral part of the aorta, leading to potentially life-threatening symptoms, such as hypertension, congestive heart failure, and limb and visceral ischemia. The patient was a 54-year-old female who presented with leg claudication and was diagnosed with CRA using computed tomography. CRA affected the descending thoracic and abdominal aortas, including the visceral portion, leading to reduced perfusion of both limbs and the left kidney. The surgical intervention involved bypass surgery from the descending thoracic aorta proximal to the CRA to the aortic bifurcation, including reimplantation of the left renal artery. Postoperative recovery was successful and the symptoms resolved. However, the patient experienced decreased right renal function due to CRA progression three years postoperatively. Given the uncertainty regarding the optimal surgical approach for CRA, long-term considerations are crucial for its management.

Adult William's Syndrome: The Cause of an Unusual Vasculopathy and Biliary Abnormalities

A man in his 50s was diagnosed with William's syndrome (WS) following the investigation of severe vasculopathy and bile duct abnormalities. The vascular lesions included: right carotid artery hypoplasia, tortuous dilated left carotid artery, severe aortic hypoplasia, and pulmonary branch arterial stenoses. The bile ducts were dilated with damaged and inflamed intrahepatic ducts. The patient had been labeled with fetal alcohol syndrome as a consequence of his mother's alcohol addiction. The etiology is thought to be the combined effects and his genetic condition and prenatal alcohol exposure.

Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective

Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.

Mid-aortic syndrome diagnosed by transesophageal echocardiogram in a patient with dilated cardiomyopathy

Mid-aortic syndrome is a rare condition characterised by segmental narrowing of the thoracoabdominal aorta. Here, we demonstrate a case of mid-aortic syndrome in a 30-month-old female who was diagnosed via transesophageal echocardiography after presenting with dilated cardiomyopathy and severe heart failure requiring placement of a left ventricular assist device.

Hypertension in the Neonatal Intensive Care Unit (NICU): A Case of Mid-Aortic Syndrome

A term baby was born with findings of edema, harsh murmur, and hypertension. Pregnancy course was complicated by hydrops fetalis. Upon birth, blood work did not reveal any abnormalities, but an echocardiogram showed patient in high-output heart failure. A computed tomography (CT) chest, abdomen, and pelvis revealed narrowing of aorta in the thoracic region to distal iliac and renal arteries, consistent with mid-aortic syndrome. Mid-aortic syndrome, which results in the narrowing of thoracic or abdominal aorta, is a rare cause of hypertension, especially in newborns. This case elucidates the importance of maintaining a broad differential when encountering an uncommon problem in a newborn.

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.

Case report: Personalized transcatheter approach to mid-aortic syndrome by in vitro simulation on a 3-dimensional printed model

An 8-year-old girl, diagnosed with mid-aortic syndrome (MAS) at the age of 2 months and under antihypertensive therapy, presented with severe systemic hypertension (>200/120 mmHg). Computed tomography (CT) examination revealed aortic aneurysm between severe stenoses at pre- and infra-renal segments, and occlusion of principal splanchnic arteries with peripheral collateral revascularization. Based on CT imaging, preoperative three-dimensional (3D) anatomy was reconstructed to assess aortic dimensions and a dedicated in vitro planning platform was designed to investigate the feasibility of a stenting procedure under fluoroscopic guidance. The in vitro system was designed to incorporate a translucent flexible 3D-printed patient-specific model filled with saline. A covered 8-zig 45-mm-long Cheatham-Platinum (CP) stent and a bare 8-zig, 34-mm-long CP stent were implanted with partial overlap to treat the stenoses (global peak-to-peak pressure gradient > 60 mmHg), excluding the aneurysm and avoiding risk of renal arteries occlusion. Percutaneous procedure was successfully performed with no residual pressure gradient and exactly replicating the strategy tested in vitro. Also, as investigated on the 3D-printed model, additional angioplasty was feasible across the frames of the stent to improve bilateral renal flow. Postoperative systemic pressure significantly reduced (130/70 mmHg) as well as dosage of antihypertensive therapy. This is the first report demonstrating the use of a 3D-printed model to effectively plan percutaneous intervention in a complex pediatric MAS case: taking full advantage of the combined use of a patient-specific 3D model and a dedicated in vitro platform, feasibility of the stenting procedure was successfully tested during pre-procedural assessment. Hence, use of patient-specific 3D-printed models and in vitro dedicated platforms is encouraged to assist pre-procedural planning and personalize treatment, thus enhancing intervention success.

Aorto-aortic bypass in an infant with middle aortic syndrome and Marfan syndrome: a 15-year follow-up

We present a 15-year follow-up after aorto-aortic bypass surgery in a 7-month-old infant with middle aortic syndrome and confirmed Marfan syndrome. In anticipation of her growth, the length of the graft was adjusted to the anticipated length of the narrowed aorta in her adolescence. In addition, her height was controlled by oestrogen, and her growth was stopped at 178 cm. To date, the patient is free from aortic reoperation and lower limb malperfusion.

Editor's Choice - Therapeutic Options and Outcomes in Midaortic Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

Midaortic syndrome (MAS) is narrowing of the distal thoracic and or abdominal aorta with congenital, inflammatory, or idiopathic aetiology. If left untreated, the prognosis is poor due to hypertensive complications. Follow up data after treatment are sparse, contrary to aortic coarctation. This study aimed to investigate hypertension during follow up after medical, endovascular, and surgical therapy in juveniles and adults.

DATA SOURCES

A meta-analysis of case series and reports was performed, focusing on the incidence of hypertension during the follow up of juvenile (i.e., age 0-17 years) and adult MAS patients after medical, endovascular, or surgical therapy.

REVIEW METHODS

Search queries were performed in PubMed, Embase, and Web of Science, and eligible articles underwent quality control. Descriptive statistics were reported based on available data, and individual patient data meta-analyses were performed using a one stage approach, accounting for clustering by case series or decades of reporting for case reports. For the meta-analysis, missing outcome and aetiology data were multiply imputed.

RESULTS

The number of juveniles and adults who underwent endovascular therapy (33.7% vs. 27.3%; p = .42) and surgery (52.2% vs. 58.0%; p = .46) was similar. At baseline, 92.4% of juveniles and 87.5% of adults were hypertensive, decreasing to 23.2% and 24.1% during a follow up of 23 months (juveniles) and 18 months (adults), respectively. More hypertension was found compared with surgery in juveniles after endovascular therapy (38.1% vs. 10.8%; p = .020). Meta-analysis also demonstrated a trend for hypertension after endovascular therapy in juveniles, whereas hypertension was more prevalent following surgery in adults compared with endovascular therapy or medication.

CONCLUSION

This review and meta-analysis investigated therapeutic options for MAS in juveniles and adults. It found that complications and hypertension during follow up were more common in juveniles after endovascular treatment, whereas surgery in adults was associated with more hypertension.

ELN missense variant in patient with mid-aortic syndrome case report

BACKGROUND

Mid-aortic syndrome (MAS) is characterized by the congenital coarctation of the abdominal aorta, abdominal and limb claudication, and hypertension. The etiology of this disorder is very diverse and often manifests in conjunction with Takayasu's arteritis, Williams-Beurens syndrome, and neurofibromatosis. The isolated mid-aortic syndrome is very rare with only a few cases reported in the literature.

CASE PRESENTATION

A 45 years old man was admitted to the Emergency Department with sudden muscle weakness and facial paralysis on the left side. Imaging studies reveal right middle cerebral artery infarction at the M1 section. Incidental findings include multiple moderate to severe stenoses in the right internal carotid artery, and total abdominal aorta occlusion. A variant at the ELN gene (Elastin, OMIM*130,160): c.1768G > A/wt (p.Ala590Thr) was identified.

CONCLUSION

This is the first reported case of ELN related mid-aortic syndrome in Vietnam which was diagnosed through careful clinical and genetic workup. The finding of mid-aortic syndrome, in this case, was incidental and the decision to reverse the occlusion was postponed as there was no immediate risk of renal failure or reduced blood flow to the lower limb.

Treatment of 12-year-old girl with midaortic syndrome by using Cook Formula stent

Middle aortic syndrome is a severe form of aortic coarctation and mostly involves the thoracic and abdominal part of the aorta. Traditional surgical approach has some potential risks and repetitive operations. Percutaneous stent implantation is a feasible and safe method for the palliation of middle aortic syndrome in childhood. Herein, a child with middle aortic syndrome was presented who has been treated by transcatheter stent implantation.

Mid-aortic syndrome: a rare cause of heart failure in infants

This case reports describe a rare disease, mid-aortic syndrome (MAS), that can cause severe heart failure and hypertension in infancy. The typical images, key points of diagnosis, and therapy methods of the disease have also been presented. We report two critical thoracoabdominal aortic coarctation cases in infants aged 2 and 11 months with severe heart failure. The patients were initially misdiagnosed as dilated myocardiopathy, with the correct diagnosis confirmed through imaging. Both patients underwent balloon angioplasty; one patient also had bare-metal stents implanted. The patient treated with balloon angioplasty alone died after the procedure, whereas the other patient recovered well. In conclusion, careful physical examinations, especially upper and lower extremity blood pressure differences and palpation of upper and lower limb pulses, are critical in unexplained infant heart failure cases. Stent implantation may be a safer and more effective treatment than simple balloon angioplasty in infants with MAS.

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.

HISTOLOGIC AND MORPHOLOGIC CHARACTER OF PEDIATRIC ABDOMINAL AORTIC DEVELOPMENTAL COARCTATION AND HYPOPLASIA

OBJECTIVES

Abdominal aortic coarctation and hypoplasia are uncommon diseases, recognized most often in pediatric-aged individuals. Comprehensive studies regarding the pathologic spectrum of these aortopathies are nonexistent. This investigation was undertaken to better define the histologic and morphologic character of abdominal aortic narrowings affecting children and assess its potential relevance to contemporary clinical practice.

METHODS

Aortic specimens obtained during open operations in children being treated for symptomatic, noninflammatory abdominal aortic narrowings at the University of Michigan were subjected to histologic study following hematoxylin-eosin, Movat, Verhoeff Van Gieson, and Masson's trichrome preparations. Microscopic findings were correlated with the anatomic aortic images. In addition, a detailed review was completed of all prior reports in the English literature that included images depicting the histologic character of noninflammatory abdominal aortic narrowings in children.

RESULTS

Among a series of 67 pediatric-aged individuals undergoing open surgical interventions for abdominal aortic narrowings, eight children ranging in age from 9 months to 18 years, had adequate aortic tissue available for study. The loci of the specimens paralleled the anatomic sites of segmental coarctations observed in the entire series, with involvement of the suprarenal abdominal aorta (3), intrarenal aorta (2), and infrarenal aorta (1). Diffusely hypoplastic abdominal aortas (2) included one case of a de facto aortic duplication, represented by a channel that paralleled the narrow native aorta and gave origin to celiac artery branches, as well as the superior mesenteric and renal arteries. Concentric or eccentric intimal fibroplasia was observed in every aorta, often with internal elastic fragmentation and duplication (4). Media abnormalities included elastic tissue disorganization (3), and focal medial fibrosis (1). Organizing luminal thrombus occurred in two infants. Coexistent ostial stenoses of the celiac, superior mesenteric, or renal arteries were observed in all but the only child who having an infrarenal aortic coarctation. Neurofibromatosis-1 affected one child whose histologic findings were indistinguishable from those of the other children. Review of prior published histologic images of abdominal aortic coarctation and hypoplasia affecting children from other centers revealed a total of 14 separate reports, each limited to single case photomicrographs of which 11 exhibited intimal fibroplasia.

CONCLUSIONS

Intimal fibroplasia is a common accompaniment of developmental abdominal aortic coarctation and hypoplasia. It is posited that intimal fibroplasia, that is likely progressive in instances of abnormal shear stresses in these diminutive vessels, may contribute to less salutary outcomes following endovascular and certain open reconstructions of pediatric abdominal aortic narrowings.

Long-segmental middle aortic coarctation: a rare case first diagnosed by transthoracic echocardiography

Background

Middle aortic coarctation (MAC), also known as middle aortic syndrome, is an atypical aortic coarctation characterized by narrowing of the distal thoracic aorta and proximal abdominal aorta. MAC is a rare disease commonly diagnosed by computed tomography angiography (CTA). In this paper, we present a case of long-segmental MAC first diagnosed by transthoracic echocardiography (TTE) and further evaluated by CTA.

Case presentation.

A 14-year-old girl, with dyspnea and fatigue on exertion for 2 months and refractory hypertension for 6 months, was referred by the local clinic to our hospital. Physical examination showed blood pressure up to 176/100 mmHg measured in the arms despite dual antihypertensives, a marked pressure gradient between her arms and legs, and weak pulses in both dorsal pedes arteries. TTE revealed a segmental narrowing in the descending thoracic aorta below the level of the atrioventricular sulcus, with a calcified plaque in the stenotic region. Abdominal vascular ultrasound revealed the segmental narrowing extending to the descending abdominal aorta (5.7 mm in diameter) above the level of the superior mesenteric artery. Subsequently, CTA verified a long-segment narrowing in the descending aorta from the level of T8 to L2 vertebra, with a calcified plaque in the stenotic aorta, right renal artery involvement, and a rich network of collateral vessels between the pre-and post-stenotic region. The patient was referred for cardiovascular surgery in which a successful ascending aorta-abdominal aorta bypass was performed.

Conclusions

Although MAC is usually diagnosed by CTA, it may also be first diagnosed by TTE in some patients whose longitudinal axis view of the thoracic descending aorta could be shown. Careful TTE scan can improve the diagnostic rate of MAC, especially for some hypertension patients whose marked pressure gradient between arms and legs was ignored by the physician.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02475-2.

Coarctação de aorta abdominal justarrenal associada à hipertensão renovascular e claudicação incapacitante: tratamento utilizando ponte ilíaco-birrenal e técnica “paving and cracking”

Resumo Coarctação da aorta abdominal é uma causa rara de claudicação de membros inferiores e hipertensão refratária. O tratamento é complexo e exige conhecimento de diversas técnicas de reconstrução vascular. Apresentamos um caso de coarctação ao nível das artérias renais, seu tratamento e revisão da literatura. Paciente feminina, 65 anos, com hipertensão refratária desde os 35 anos, utilizando cinco medicações anti-hipertensivas em dose máxima. Pressão arterial média de 260/180mmHg e claudicação incapacitante (menos de 20 metros) bilateral. Angiotomografia computadorizada demonstrou coarctação de aorta justarrenal de 4 mm de maior diâmetro, calcificação circunferencial no local da estenose e tortuosidade da aorta infrarrenal. Foi submetida a tratamento híbrido, com ponte ilíaco-birrenal e implante de stent Advanta V12 no local da estenose. A paciente evoluiu satisfatoriamente e, 60 dias depois da cirurgia, apresentava-se com uma pressão arterial de 140/80mmHg, em uso de apenas duas medicações anti-hipertensivas e sem claudicação.

Complex Multi-Stage Total Aortic and Subclavian Artery Replacement in a 9-year old boy with Loeys-Dietz-Syndrome

BACKGROUND

Loeys-Dietz Syndrome is a rare connective tissue disorder that is associated with arterial pathologies such as aortic dissections, tortuosity and aneurysms.We present a child with Loeys-Dietz Syndrome type 2 that received total aortic and bilateral subclavian artery replacement.

CASE REPORT

A 9-year old boy with Loeys-Dietz Syndrome type 2 and acute type B aortic dissection received an urgent complete thoracic and thoraco-abdominal aortic repair within three days. First, the ascending aorta and aortic root were replaced in a Tirone David and Frozen Elephant Trunk procedure. Then, the descending and supramesenteric aorta was replaced by a Dacron interposition graft with direct implantation of the celiac trunk. During the 15 months follow-up, the patient required three more surgical interventions for rapid expanding aneurysms of both subclavian arteries and the infrarenal aorta. No major adverse event nor secondary interventions occurred. Ultrasonographic and magnetic resonance imaging follow-up is continued at 6-months intervals.

CONCLUSION

Children with Loeys-Dietz Syndrome may require extensive aortic repair for aortic dissection and show rapidly expanding aneurysms. Referral to a center with pediatric vascular expertise and long-term follow-up examinations are crucial.

The Use of Systematic Clinical Approach in Diagnosing Rare Cases of Secondary Hypertension: A Case Report of Mid Aortic Syndrome in a Young Patient

Mid aortic syndrome (MAS) is a rare disease that occurs in children and young adults. The most important clinical feature reflecting vascular involvement is the presence of systemic hypertension. The diagnosis is usually made during the imaging assessment of secondary hypertension when routine echocardiography fails to identify the characteristic morphological or Doppler flow patterns associated with thoracic arch coarctation in the presence of the clinical features of aortic vascular obstruction. In this report, we present a case of a 22-year-old male who presented with systemic hypertension not responding to medical treatment, and whose systematic diagnostic workup revealed the diagnosis of MAS involving both renal arteries.

Stenotic lesions of aorta: Imaging evaluation using multidetector computed tomography angiography

Aortic involvement can be secondary to various pathologic disease processes. These may result in stenotic or aneurysmal aortic lesions with a varied spectrum of imaging findings including intra-luminal, mural, and periaortic changes along with associated loco-regional or distal changes, depending on the etiology. Multidetector computer tomography with its recent advances has become the frontline imaging modality for the evaluation of aortic pathologies. Comprehensive evaluation of the aortic pathology with simultaneous evaluation of lungs, bones, and visceral organs is possible with a single multidetector computer tomography acquisition. It allows accurate primary diagnosis, identifies important anatomic landmarks and relationships, and identifies associated cardiovascular anomalies. Moreover, it serves as an adjunct in diagnosis of various complications, helps in treatment planning and detection of disease progression during follow-up.

Intravascular lithotripsy-assisted balloon angioplasty to facilitate transfemoral transcatheter aortic valve implantation in a patient with coral reef aorta

This case describes the management of a woman in her 70s with severe symptomatic aortic stenosis and concomitant severe stenosis of the suprarenal abdominal aorta due to 'coral reef' calcification of the aortic wall and lumen (CRA). Due to her religious beliefs as a Jehovah's Witness regarding the use of blood products, she rejected the option of surgical aortic valve replacement. Transfemoral (TF) delivery of a transcatheter aortic valve was challenged by the presence of CRA. A successful TF transcatheter aortic valve implantation (TAVI) was achieved by the treatment of the CRA with intravascular lithotripsy-assisted angioplasty, followed by delivery and deployment of a self-expanding TAVI valve.

Sonographic findings in mid-aortic syndrome

Mid-aortic syndrome (MAS) is an uncommon condition characterised by narrowing of the distal descending thoracic or abdominal aorta. While CT, MR and conventional angiography findings in MAS are well described, there have been very few cases which clearly document the sonographic features of this condition. This case report demonstrates the utility of ultrasound in the investigation of MAS and summarises the current literature surrounding the condition.

Renovascular hypertension in children

Paediatric hypertension, defined as systolic blood pressure > 95th percentile for age, sex and height is often incidentally diagnosed. Renovascular hypertension (RVH) is responsible for 5-25% of hypertension in children. Renal artery stenosis and middle aortic syndrome can both can be associated with various conditions such as fibromuscular dysplasia, Williams syndrome & Neurofibromatosis type 1. This paper discusses the approaches to diagnosis and interventional management and outcomes of renovascular hypertension in children. Angiography is considered the gold standard in establishing the diagnosis of renovascular disease in children. Angioplasty is beneficial in the majority of patients and generally repeated angioplasty is considered more appropriate than stenting. Surgical options should first be considered before placing a stent unless there is an emergent requirement. Given the established safety and success of endovascular intervention, at most institutions it remains the preferred treatment option.

Idiopathic midaortic syndrome

Midaortic syndrome (MAS) is characterized by narrowing of the descending aorta between the distal aortic arch and the aortic bifurcation. We present the case of a 4-year-old male presenting with a murmur and diagnosed with MAS. He was treated with a thoracoabdominal bypass graft.

Surgical management of pediatric renovascular hypertension and midaortic syndrome at a single-center multidisciplinary program

OBJECTIVE

To evaluate the outcomes of various surgical approaches in the treatment of renovascular hypertension and midaortic syndrome (MAS) in children.

METHODS

We performed a retrospective medical record review of patients who had undergone surgery for renovascular hypertension from 2010 to 2018 at our center under the care of a multidisciplinary team. The operative interventions included mesenteric artery growth improves circulation (MAGIC), tissue expander-stimulated lengthening of arteries (TESLA), aortic bypass using polytetrafluorethylene, renal artery reimplantation, and autotransplantation. The MAGIC procedure uses the meandering mesenteric artery as a free conduit for aortic bypass. The TESLA procedure is based on lengthening the normal distal aorta and iliac arteries by gradual filling of a retroaortic tissue expander for several weeks, followed by resection of the stenotic aorta and subsequent primary reconstruction.

RESULTS

A total of 39 patients were identified, 10 with isolated renal artery stenosis, 26 with MAS, and 3 with systemic inflammatory vasculitis. The median age at presentation and surgery was 6.4 years (range, 0-16.3 years) and 9.3 years (range, 0-9.2 years), respectively. The MAS-associated syndromes included neurofibromatosis type 1 (15.4%) and Williams syndrome (5.1%), although most cases were idiopathic. At surgery, 33.3% had had stage 1 hypertension (HTN), 53.8% stage 2 HTN, and 12.8% normal blood pressure with a median of three antihypertensive medications. Follow-up of 37 patients at a median of 2.5 years demonstrated normal blood pressure in 86.1%, stage 1 HTN in 8.3%, and stage 2 HTN in 5.6%, with a median of one antihypertensive medication for the entire cohort.

CONCLUSIONS

The patterns of vascular involvement leading to renovascular hypertension in children are variable and complex, requiring thoughtful multidisciplinary planning and surgical decision-making. The MAGIC and TESLA procedures provide feasible approaches for aortic bypass and reconstruction using autologous tissues and will result in normalization of blood pressure in 85% of children 2.5 years after surgery.

Winslow Pathway Collaterals: An Unusual Arterial Network in Takayasu Arteritis

Takayasu arteritis which is reported more commonly from Asia and in females can present as middle aortic syndrome with lower limb claudication. We present a case of a young male with Takayasu arteritis with middle aortic syndrome and Winslow pathway collaterals with lower limb ischaemia, hypertension, coronary occlusion and stroke. The extensive collateral formation was visible as a clinical finding over the abdominal wall. The identification of these collateral pathways is essential in understanding the extent of haemodynamically significant disease and it alerts to the possibility of surgical injury during procedures like laparotomy or harvesting of internal thoracic artery for coronary artery bypass graft.

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.

Fetal congenital midaortic syndrome with unilateral renal artery stenosis prenatally presenting with polyhydramnios and postpartum as hyponatremic hypertensive syndrome

The midaortic syndrome (MAS) is a rare anomaly, characterised by narrowing of the distal aorta and its major branches. The most common symptom is severe arterial hypertension. The combination of hyponatremia, polyuria and renovascular hypertension caused by a unilateral renal artery stenosis is described as hyponatremic hypertensive syndrome. We report a case of MAS with unilateral renal artery stenosis in a preterm female neonate. A pregnant woman at 34 weeks of gestation was referred with fast growing abdominal circumference and pain. The ultrasound revealed severe polyhydramnios and fetal myocardial hypertrophy. Within the first 48 hours of the neonatal period, the diagnosis of MAS was made. We conclude that symptomatic MAS, caused by unilateral renal artery stenosis, resulting in increased renin-angiotensin-aldosterone system activity and subsequent polyuria of the non-stenotic kidney, lead to clinically significant polyhydramnios.

Normative and pathological values of hemodynamic and Doppler ultrasound arterial findings in children

Doppler ultrasound is an effective, useful and remarkably powerful tool in pediatric imaging. If possible, its use is always favored to avoid exposure to radiation or sedatives. By waveform spectrum analysis, Doppler ultrasound reveals information on blood flow and details on normal physiology and pathological processes undiscernible from gray-scale imaging alone. However, Doppler ultrasound remains underused, largely due to the difficult interpretation of changes in Doppler waveforms during childhood. This article provides a narrative review of the literature regarding the normative values and the physiological arterial changes through childhood according to age, weight or height, as well as frequent pathological arterial findings in children, classified by arterial territory.

The importance of FDG PET/CT in the diagnostic process of the middle aortic syndrome in a 15-year-old boy patient with suspected systemic vasculitis and final diagnosis of Williams-Beuren syndrome

The differential diagnosis in children with the systemic vasculopathy is still a challenge for clinicians. The progress in vascular imaging and the latest recommendations improve the diagnostic process, but only single reports describe the use of new imaging tests in children. The publication aims to demonstrate the important role of 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography combined with anatomical computed tomography angiography (PET/CTA) imaging in the case of a 15-year-old boy with chest pain, intermittent claudication, hypertension and features of middle aortic syndrome in computed tomography angiography (CTA). The patient was suspected to have Takayasu arteritis, but was finally diagnosed with Williams–Beuren syndrome. The case indicates that the FDG PET/CT imaging might be essential in the diagnostic process of middle aortic syndrome in children. We suggest that this imaging technique should be considered in the diagnostic process of systemic vasculopathy particularly in children.

Surgical management of middle aortic syndrome in an adult

Middle aortic syndrome (MAS), a coarctation of the lower thoracic and/or abdominal aorta, is typically diagnosed and treated in the pediatric population. We present a 48-year-old patient with a long-standing history of hypertension who was lost to follow-up owing to a lack of insurance coverage. After two myocardial infarcts owing to severe hypertension, a vascular workup including a computed tomography angiogram revealed a diagnosis of MAS. He underwent open vascular reconstruction with a thoracoabdominal Dacron bypass graft. He was discharged within 1 week with no hypertension or claudication. Adult patients diagnosed with MAS should undergo open or endovascular surgical repair with close follow-up.

Computational analysis of renal artery flow characteristics by modeling aortoplasty and aortic bypass interventions for abdominal aortic coarctation

OBJECTIVE

Suprarenal abdominal aortic coarctation (SAAC) alters flow and pressure patterns to the kidneys and is often associated with severe angiotensin-mediated hypertension refractory to drug therapy. SAAC is most often treated by a thoracoabdominal bypass (TAB) or patch aortoplasty (PA). It is currently unclear what effect these interventions have on renal flow and pressure waveforms. This study, using retrospective data from a patient with SAAC subjected to a TAB, undertook computational modeling to analyze aortorenal blood flow preoperatively as well as postoperatively after a variety of TAB and PA interventions.

METHODS

Patient-specific anatomic models were constructed from preoperative computed tomography angiograms of a 9-year-old child with an isolated SAAC. Fluid-structure interaction (FSI) simulations of hemodynamics were performed to analyze preoperative renal flow and pressure waveforms. A parametric study was then performed to examine the hemodynamic impact of different bypass diameters and patch oversizing.

RESULTS

Preoperative FSI results documented diastole-dominated renal perfusion with considerable high-frequency disturbances in blood flow and pressure. The postoperative TAB right and left kidney volumes increased by 58% and 79%, respectively, reflecting the increased renal artery blood flows calculated by the FSI analysis. Postoperative increases in systolic flow accompanied decreases in high-frequency disturbances, aortic pressure, and collateral flow after all surgical interventions. In general, lesser degrees of high-frequency disturbances followed PA interventions. High-frequency disturbances were eliminated with the 0% PA in contrast to the 30% and 50% PA oversizing and TAB interventions, in which these flow disturbances remained.

CONCLUSIONS

Both TAB and PA dramatically improved renal artery flow and pressure waveforms, although disturbed renal waveforms remained in many of the surgical scenarios. Importantly, only the 0% PA oversizing scenario eliminated all high-frequency disturbances, resulting in nearly normal aortorenal blood flow. The study also establishes the relevance of patient-specific computational modeling in planning interventions for the midaortic syndrome.