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Complex Aortic Reconstruction For Type Iv Mid Aortic Syndrome
Pierce Leroux Massie, Hamza Hanif, Rachel Dancyzk, Ross Clark, LeAnn Chavez, Muhammad A. Rana.
University of New Mexico, ALBUQUERQUE, NM, USA.
We present a complex aortic reconstruction for a 15 year old male with a history of obesity who presented with type IV mid aortic syndrome complicated by renovascular hypertension and signs and symptoms of heart failure. He underwent an aortogram which demonstrated a gradient of 80 mm Hg between the distal descending thoracic aorta and infrarenal aorta, in addition to a gradient of 30 mm Hg between both renal arteries and the adjacent native aorta. Considering he had absent mesenteric symptoms, the primary target for reconstruction was at the infrarenal aorta and bilateral renal arteries. He would undergo a distal thoracic to infrarenal aortic bypass with a 16 mm Hemashield graft in an end-to-side fashion through a left posterolateral thoracotomy and left flank retroperitoneal incision. His graft was tunneled through the diaphragmatic hiatus from the chest into the retroperitoneum after it was opened two centimeters. His right renal artery was ligated proximally and bypassed with a 7 mm Hemashield graft in an end-to-side fashion from the graft to the distal artery. His left renal artery was initially reimplanted, but no flow was detected after reimplantation. He thus underwent a reversed saphenous vein graft bypass from his graft to the left renal artery in an end-to-side fashion both proximally and distally. There was concern that his graft may steal too much flow from his native aorta supplying his visceral vessels, but his infrarenal aorta proximal to the bypass was inflamed and deemed inappropriate for ligation. Thus, a second stage endovascular occlusion with an Amplatzer plug was performed in the native aorta proximal to the infrarenal bypass and inferior mesenteric artery to prevent competitive flow. His postoperative course was notable for brief renal failure requiring continuous renal replacement therapy that resolved. His hypertension is now controlled on labetalol monotherapy, and he takes aspirin 162 mg daily for antiplatelet therapy. His signs and symptoms of heart failure have resolved and the patient will return to clinic in one year for a duplex of his renal arteries.
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