Abdominal aorta coarctation: The first three case reports in our literature

Correspondence to: Slobodan TANASKOVIĆ Institut za kardiovaskularne bolesti „Dedinje” Heroja Milana Tepića 1 11000 Beograd, Srbija drslobex@gmail.com

Коарктација трбушне аорте – приказ прва три

случаја у нашој литератури

Предраг Гајин, Слободан Танасковић, Драгослав Ненезић, Ненад Илијевски, Ђорђе Радак

Институт за кардиоваскуларне болести „Дедиње”, Београд, Србија

UVOD

Su­že­we­aor­te­od­odva­ja­wa­bra­hi­o­ce­fa­lič­ nog­sta­bla­do­bi­fur­ka­ci­je­na­zi­va­se­ko­ark­ ta­ci­ja.­Ko­ark­ta­ci­ja­tr­bu­šne­aor­te­(KTA)­je­ ve­o­ma­ret­ko­obo­qe­we­i­či­ni­sve­ga­0,5­2%­ svih­ko­ark­ta­ci­ja­[1,­2,­3].­U­an­glo­sak­son­ skoj­li­te­ra­tu­ri­ovo­te­ško­obo­qe­we­po­zna­ to­je­pod­ime­ni­ma­mid dle aor tic syndro me i­ mid-aor tic dyspla stic syndro me.­Pre­ma­lo­ka­li­ za­ci­ji,­mo­že­se­po­de­li­ti­na­su­pra­re­nal­nu­ (naj­če­šća),­in­ter­re­nal­nu,­in­fra­re­nal­nu­i­ di­fu­znu­for­mu.­Ste­no­za­vi­sce­ral­nih­ar­te­ ri­ja­ja­vqa­se­u­26%­slu­ča­je­va,­mul­ti­ple­re­ nal­ne­ar­te­ri­je­se­be­le­že­u­70%,­dok­se­kod­ 84%­bo­le­sni­ka­di­jag­no­sti­ku­je­ste­no­za­re­ nal­nih­ar­te­ri­ja­[1,­4,­5,­6].

Ovo­ret­ko­obo­qe­we­je­po­sle­di­ca­kon­ge­ ni­tal­ne­hi­po­pla­zi­je­ili­ano­ma­li­je­raz­vo­ ja,­ali­se­kao­eti­o­lo­ški­fak­to­ri­po­mi­wu­ i­ne­u­ro­fi­bro­ma­to­za­[7­10],­zrač­na­te­ra­pi­ ja,­fo­kal­na­ate­ro­skle­ro­za­[11],­ne­spe­ci­fič­ ni­–­Ta­ka­ja­su­ov­(Ta kayasu)­aor­to­ar­te­ri­tis­ [2,­12­15]­i­fi­bro­mu­sku­lar­na­dis­pla­zi­ja­ [16].­Ob­ja­vqen­je­i­slu­čaj­KTA­iza­zva­ne­po­ sta­vqe­wem­ka­te­te­ra­kroz­pup­ča­nu­ar­te­ri­ ju­no­vo­ro­đen­če­ta­[17].­KTA­se­pr­ven­stve­no­ ja­vqa­kod­mla­dih­oso­ba­(pro­sek­20­go­di­na)­ [3],­prem­da­se­mo­že­ot­kri­ti­u­bi­lo­ko­jem­ ži­vot­nom­do­bu.­Dva­glav­na­simp­to­ma­ovog­

obo­qe­wa­su­re­no­va­sku­lar­na­hi­per­ten­zi­ja,­ od­no­sno­se­kun­dar­ne­se­kve­le­du­go­go­di­šwe­ hi­per­ten­zi­je,­kao­i­in­ter­mi­tent­ne­kla­u­ di­ka­ci­je­do­wih­eks­tre­mi­te­ta­[1,­18].­Tre­ ći­simp­tom,­ko­ji­se­re­đe­ja­vqa,­je­ste­tr­bu­ šna­an­gi­na­[1,­18,­19].

Zlat­ni­stan­dard­me­đu­di­jag­no­stič­kim­ pro­ce­du­ra­ma­je­ar­te­ri­o­gra­fi­ja­[1,­18],­ko­ jom­se­ot­kri­va­ju­me­sto­i­op­seg­ste­no­ze­i­za­ hva­će­nost­vi­sce­ral­nih­gra­na­aor­te.­Neo­p­ hod­na­je­za­pro­ce­nu­iz­bo­ra­en­do­va­sku­lar­ nog­ili­hi­rur­škog­vi­da­le­če­wa.

PRIKAZI BOLESNIKA

U­pe­ri­o­du­1996­2007.­go­di­ne­re­tro­spek­tiv­ no­i­pro­spek­tiv­no­su­usta­no­vqe­na­tri­bo­ le­sni­ka­kod­ko­jih­je­di­jag­no­sti­ko­va­na­KTA.­ Ana­li­zi­ra­ni­su­kli­nič­ki­simp­to­mi­(in­ ter­mi­tent­ne­kla­u­di­ka­ci­je­i­se­kun­dar­ne­se­ kve­le­ar­te­rij­ske­hi­per­ten­zi­je)­i­zna­ci­bo­ le­sti.­Od­ne­in­va­ziv­nih­me­to­da­di­jag­no­sti­ ke­pri­me­we­ni­su­do­pler­ul­tra­zvuč­na­pro­ ce­na­pe­ri­fer­ne­is­he­mi­je­(pe­do­bra­hi­jal­ni­ in­dek­si­–­PBI)­i­uobi­ča­je­no­me­re­we­ar­te­ rij­skog­pri­ti­ska.­Od­in­va­ziv­nih­po­stu­pa­ ka­pri­me­we­na­je­ar­te­ri­o­gra­fi­ja,­na­osno­vu­ ko­je­je­po­sta­vqa­na­di­jag­no­za­i­vr­še­na­pro­ ce­na­vr­ste­le­če­wa.­Bo­le­sni­ci­su­le­če­ni­hi­

KRATAK SADRŽAJ

Uvod U kli nič koj prak si do bro je po zna ta kon ge ni tal na ko ark ta ci ja grud ne aor te u ni vou li ga men ta ar te ri o zu ma ili aort nog lu ka. Mno go je re đa ko ark ta ci ja dis tal nog de la grud ne ili tr bu šne aor te (0,5-2%), ko ja je u an glo sak son skoj li te ra tu ri po zna ta pod ime ni ma mid dle aor tic syndro me i mid-aor tic dyspla stic syndro me. To je te ško obo qe we či je le če we zah te va mul ti di sci pli na ran pri stup.

Pri ka zi bo le sni ka U pe ri o du 1996-2007. go di ne na Kli ni ci za va sku lar nu hi rur gi ju In sti tu ta za kar di o va sku lar ne bo le sti „De di we” u Be o gra du le če na su tri bo le sni ka zbog ko ark ta ci je tr bu šne aor te (dve že ne sta re 50 i 55 go di na i če tvo ro go di šwi de čak). Oni su kli nič ki pra će ni 51-118 me se-ci. Bo le sni ci su le če ni hi rur ški baj pa som ve štač kim graf tom i tzv. pač (engl. patch) an gi o pla sti-kom i en do va sku lar no per ku ta nom tran slu mi nal nom an gi o pla sti sti-kom (PTA) sa sten tom ili bez we ga. Kod pe de se to go di šwe bo le sni ce an gi o graf ski na laz je po ka zao zna čaj no su že we su pra re nal nog seg-men ta tr bu šne aor te. Ura đen je to ra ko-ab do mi nal ni baj pas tu bu lar nim da kron skim graf tom preč-ni ka 16 mm. Kod de ča ka je an gi o gra fi jom ta ko đe po tvr đe na ko ark ta ci ja su pra re nal nog de la aor te. U pr vom ak tu pri me we na je „pač” an gi o pla sti ka, a za tim u ne ko li ko na vra ta PTA vi sce ral nih ar te ri ja. Kod pe de set pe to go di šwe bo le sni ce di jag no sti ko va na je ko ark ta ci ja tr bu šne aor te u in fra re nal-nom seg men tu. Ura đe na je PTA uz pri me nu sten ta. Na kon trol nim pre gle di ma sva tri bo le sni ka su bi-la bez simp to ma obo qe wa.

Za kqu čak Ko ark ta ci ja tr bu šne aor te je pa to lo ški en ti tet ko ji se iz u zet no ret ko sre će u va sku lar-noj hi rur gi ji. An gi o gra fi ja je od ve li kog zna ča ja za po sta vqa we di jag no ze i ne po sred nu kon tro lu re-zul ta ta hi rur škog i ne hi rur škog le če wa. Kom bi na ci ja hi rur škog i en do va sku lar nog le če wa je kod na ših bo le sni ka da la vr lo do bre re zul ta te u po sma tra nom pe ri o du.

rur­ški­baj­pas­po­stup­kom­i­tzv.­pač­(engl.­patch)­an­gi­ o­pla­sti­kom­i­en­do­va­sku­lar­no­per­ku­ta­nom­tran­slu­mi­ nal­nom­an­gi­o­pla­sti­kom­(PTA)­sa­sten­tom­ili­bez­we­ ga.­Pe­riod­kli­nič­kog­pra­će­wa­tra­jao­je­51­118­me­se­ci.

Prvi bolesnik

Go­di­ne­1996.­na­Kli­ni­ku­za­va­sku­lar­nu­hi­rur­gi­ju­In­ sti­tu­ta­„De­di­we”­pri­mqe­na­pe­de­se­to­go­di­šwa­že­na­ ko­ja­je­ne­ko­li­ko­go­di­na­ra­ni­je­ima­la­in­ter­mi­tent­ne­ kla­u­di­ka­ci­je­i­hi­per­ten­ziv­nu­en­ce­fa­lo­pa­ti­ju.­To­kom­ kli­nič­kog­pre­gle­da­usta­no­vqen­je­iz­o­sta­nak­ar­te­rij­ skih­pul­za­ci­ja­u­obe­pre­po­ne.­PBI­su­na­obe­stra­ne­ bi­li­0,61.­Ar­te­ri­o­gram­je­ot­krio­hi­po­pla­zi­ju­aor­te­ u­su­pra­re­nal­nom­seg­men­tu­(Sli­ka­1).­

Bo­le­sni­ca­je­ope­ri­sa­na­u­ok­to­bru­iste­go­di­ne,­a­po­ to­ra­ko­fre­no­la­pa­ro­to­mi­ji­ura­đen­je­aort­no­aort­ni­ baj­pas­da­kron­skim­tu­bu­lar­nim­graf­tom­preč­ni­ka­16 mm.­Obe­ana­sto­mo­ze­su­kre­i­ra­ne­po­ti­pu­T­L,­prok­ si­mal­na­je­for­mi­ra­na­na­za­vr­šni­deo­grud­ne­aor­te­ (Sli­ka­2),­a­dis­tal­na­na­in­fra­re­nal­ni­seg­ment­tr­bu­ šne­aor­te­(Sli­ka­3).­To­kom­ope­ra­ci­je­je­utvr­đe­no­da­

su­obe­re­nal­ne­ar­te­ri­je­za­do­vo­qa­va­ju­ćeg­preč­ni­ka­i­da­ će­pro­tok­kroz­wih­bi­ti­od­go­va­ra­ju­ći,­te­se­od­u­sta­lo­ od­wi­ho­ve­re­kon­struk­ci­je,­što­se­pre­hi­rur­škog­le­ če­wa­raz­ma­tra­lo­kao­mo­guć­nost.

Drugi bolesnik

Go­di­ne­1998.­na­bol­nič­ko­le­če­we­je­pri­mqen­če­tvo­ ro­go­di­šwi­de­čak­kod­ko­jeg­je­od­kli­nič­kih­simp­to­ ma­do­mi­ni­ra­la­hi­per­ten­ziv­na­en­ce­fa­lo­pa­ti­ja,­a­dve­ go­di­ne­ra­ni­je­po­gre­šno­je­le­čen­pod­di­jag­no­zom­epi­ lep­si­je.­Pre­pon­ske­pul­za­ci­je­bi­le­su­je­dva­pal­pa­bil­ ne,­a­PBI­su­bi­li­0,55­na­obe­stra­ne.­Ar­te­ri­o­gra­fi­ jom­je­po­tvr­đe­na­di­fu­zna­ste­no­za­su­pra­re­nal­ne­i­in­ fra­re­nal­ne­aor­te,­uz­po­sto­ja­we­le­ve­ak­ce­sor­ne­re­nal­ ne­ar­te­ri­je­(Sli­ka­4).­

Bo­le­snik­je­ope­ri­san­u­no­vem­bru­iste­go­di­ne­ta­ko­ đe­pri­me­nom­to­ra­ko­fre­no­la­pa­ro­to­mi­je,­uz­le­vo­stra­ nu­me­di­jal­nu­vi­sce­ral­nu­ro­ta­ci­ju­po­Me­tok­su­(Mat-tox).­Pri­me­we­na­je­„pač”­an­gi­o­pla­sti­ka­su­že­nog­seg­ men­ta­te­flon­skom­za­kr­pom­(Sli­ka­5).­Zbog­ste­no­za­vi­ sce­ral­nih­gra­na­tr­bu­šne­aor­te,­bo­le­sni­ku­je­u­tri­na­ vra­ta­ura­đe­na­PTA:­ne­po­sred­no­na­kon­ope­ra­ci­je­uči­ Слика 1. Коарктација супрареналне артерије код педесетого ди­

шње болеснице

Figure 1. Suprarenal coarctation in a fifty­year­old female patient

Слика 2. Артериограм после аорто­аортног бајпаса (проксимална анастомоза)

Figure 2. Arteriography after aorto­aortal by­pass (proximal ana­ stomosis)

Слика 3. Артериограм после аорто­аортног бајпаса (дистална анастомоза)

Figure 3. Arteriography after aorto­aortal bypass (distal anastomosis)

Слика 4. Дифузна форма коарктације трбушне аорте код четворо­ го дишњег дечака

Слика 5. Артериограм после „пач” ангиопластике трбушне аорте Figure 5. Arteriography after abdominal aorta patch angioplasty

Слика 6. Коарктација инфрареналне артерије код педесетпето­ го дишње болеснице

Figure 6. Infrarenal coarctation in a fifty­five­year­old female patient

Слика 7. Артериограм после ПТА и уградње стента Figure 7. Arteriography after PTA and stent placement we­na­je­PTA­le­ve­re­nal­ne­i­ak­ce­sor­ne­re­nal­ne­ar­te­

ri­je,­go­di­nu­da­na­ka­sni­je­gor­we­me­zen­te­rič­ne­i­de­sne­ re­nal­ne­ar­te­ri­je,­a­na­kon­dve­go­di­ne­trun­ku­sa­ce­li­ ja­ku­sa­i­po­no­vo­de­sne­re­nal­ne­ar­te­ri­je.

Treći bolesnik

U­apri­lu­2003.­go­di­ne­na­bol­nič­ko­le­če­we­je­pri­mqe­ na­pe­de­se­to­go­di­šwa­že­na­kod­ko­je­su­od­kli­nič­kih­ simp­to­ma­do­mi­ni­ra­le­in­ter­mi­tent­ne­kla­u­di­ka­ci­je­ uz­nor­mal­ne­vred­no­sti­ar­te­rij­skog­pri­ti­ska.­Pre­pon­ skih­pul­za­ci­ja­na­obe­stra­ne­ni­je­bi­lo,­a­PBI­je­bio­ 0,66.­Ar­te­ri­o­gram­je­po­tvr­dio­pr­ste­na­stu­su­bo­klu­zi­ ju­in­fra­re­nal­nog­seg­men­ta­tr­bu­šne­aor­te­(Sli­ka­6).­

U­ma­ju­iste­go­di­ne­bo­le­sni­ca­je­pod­vrg­nu­ta­le­če­ wu­pri­me­nom­PTA­uz­po­sta­vqa­we­sten­ta­na­me­stu­ko­ ark­ta­ci­je­(Sli­ka­7).

DISKUSIJA

Aort­no­aort­ni­baj­pas­je­ide­a­lan­po­stu­pak­za­re­ša­va­ we­is­he­mi­je­do­wih­eks­tre­mi­te­ta­[1,­18,­20,­21],­a­ade­ kvat­na­re­gu­la­ci­ja­ar­te­rij­skog­pri­ti­ska­pri­mar­ni­ ciq­le­če­wa­bo­le­sni­ka­sa­KTA.­Bu­du­ći­da­je­hi­per­ ten­zi­ja­do­mi­nan­tan­simp­tom,­re­va­sku­la­ri­za­ci­ja­bu­ bre­ga­je­iz­u­zet­no­va­žna.­Pri­me­wu­ju­se­re­im­plan­ta­ ci­ja­re­nal­nih­ar­te­ri­ja,­„pač”­pla­sti­ka,­in­ter­po­zi­ci­ ja­i­baj­pas­pro­ce­du­re­(aor­to­re­nal­ni,­ili­jač­no­re­nal­ ni,­he­pa­to­re­nal­ni­i­sple­no­re­nal­ni­baj­pas)­[4,­22­25],­ a­po­ne­kad­je­neo­p­hod­na­i­ne­frek­to­mi­ja­[26,­27].­Sve­ vi­še­auto­ra­iz­ve­šta­va­o­uspe­hu­PTA­[28­31]­i­po­stu­ pa­ka­ugrad­we­sten­ta­[32,­33,­34]­kod­KTA,­pa­i­kod­Ta­ ka­ja­su­o­vog­ar­te­ri­ti­sa.

Le­če­we­sva­tri­bo­le­sni­ka­pri­ka­za­na­u­ovom­ra­du­ pro­te­klo­je­bez­kom­pli­ka­ci­ja.­Na­svim­kon­tro­la­ma­

PBI­su­bi­li­u­fi­zi­o­lo­škim­gra­ni­ca­ma,­a­obe­bo­le­ sni­ce,­kod­ko­jih­su­pre­le­če­wa­di­jag­no­sti­ko­va­ne­in­ ter­mi­tent­ne­kla­u­di­ka­ci­je,­bi­le­su­bez­simp­to­ma­obo­ qe­wa.­Kod­bo­le­sni­ce­i­de­ča­ka­ko­ji­su­bo­lo­va­li­od­hi­ per­ten­ziv­ne­en­ce­fa­lo­pa­ti­je­vred­no­sti­ar­te­rij­skog­ pri­ti­ska­la­ko­su­se­kon­tro­li­sa­le­ma­lim­do­za­ma­be­ ta­blo­ka­to­ra.

LITERATURA

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33. Eliason JL, Passman MA, Guzman RJ, Naslund TC. Durability of percutaneus angioplasty and stent implantation for the treatment of abdominal aortic coarctation. Vasc Surg. 2001; 35(5):397­401. 34. Brzezinska­Rajszys G, Qureshi SA, Ksiazyk J, Zubrzycka M, Kosciesza

SUMMARY

Introduction Congenital coarctation of the thoracic aorta at the ligamentum arteriosum or the aortic arch is well recognized. But a much less common variety (0.5­2.0%) of aortic coarcta­ tion is located in the distal thoracic aorta or abdominal aorta or both and is often called ”middle aortic syndrome” or ”mid­ aortic dysplastic syndrome”. This represents serious pathologi­ cal condition and indicates multidisciplinary therapy approach. Outline of Cases From 1996 to 2007, at the Vascular Surgery Clinic of the Institute for Cardiovascular Diseases „Dedinje”, Belgrade, three patients were treated due to abdominal aorta coarctation, two females aged 55 and 50 and a 4­year­old child. The patients were treated surgically (by­pass with a prosthetic graft and patch angioplasty) and endovascular­ percutaneous transluminal angioplasty (PTA) with and without a stent. The follow­up period was 3­70 months. In the 50­year­old patient, angiography showed severe narrowing of the suprarenal

segment of the abdominal aorta. Thoraco­abdominal bypass with a 16 mm dacronic tubular graft was performed. In the 4­year­old patient angiography also showed a suprarenal aorta narrowing. In the first act patch angioplasty was performed and after PTA of the visceral arteries was done on several occasions. In the 55­year­old patient, after diagnostic angiography, infra­ renal aorta coarctation was registered. PTA was performed with stent placement. All patients were asymptomatic on control check­ups.

Conclusion Abdominal coarctation is a pathological disease which is seldom found in vascular surgery. Angiography is of major importance for setting the diagnosis and for the control of the results of surgical and nonsurgical treatment. The combi­ nation of surgical and endovascular treatment in our patients showed very good results in the studied period.

keywords: abdominal aorta coarctation; transluminal percu­ taneus angioplasty; surgical treatment

Abdominal Aorta Coarctation: The First Three Case Reports in Our Literature

Predrag Gajin, Slobodan Tanasković, Dragoslav Nenezić, Nenad Ilijevski, Djordje Radak Institute for Cardiovascular Diseases ”Dedinje”, Belgrade, Serbia