Open Surgical Treatment of a Severe Case of Obstructive Calcifying Aortic Disease

Abstract

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.Severe stenosis or total occlusion of the descending aorta usually involving the origin of the visceral and renal arteries is a rare pathologic entity usually called middle aortic syndrome. 1 The commonest etiologies are congenital disorders or inflammatory disease, and adolescents or young people are more commonly affected. Herein, we describe the case of an unusual localization limited to the descending aorta and not involving the visceral vessels without any congenital or inflammatory explanation. CASE REPORTA 65-year-old woman was admitted to our department because of worsening intermittent claudication of the lower limbs and uncontrolled severe hypertension despite 3 medications (b blockers, diuretic, a1-adrenergic blocker). Her past medical history also included type 2 diabetes mellitus treated with oral hypoglycemic agents and dyslipidemia treated with statins; no history of smoke was present. Over the past months, she experienced worsening of general health, with episodes of intense asthenia, headache, dizziness and disorientation, and dyspnea after mild exertion. Physical examination revealed bilateral hyposphygmic femoral pulses and the absence of peripheral pulses. Ankle-brachial index (ABI) was 0.3 on both sides.Echo-color Doppler of the proximal abdominal aorta and iliac arteries showed poststenotic flow in the celiac trunk, superior mesenteric artery, both renal arteries, and the iliac and femoropopliteal axes bilaterally. The supra-aortic vessels appeared normal. Echocardiography demonstrated mild left ventricular hypertrophy, ectasia of the ascending aorta, and calcific stenosis of the descending aorta downstream from the isthmus. A computed tomography angiography (CTA) showed a normal ascending aorta and aortic arch, a severely calcified descending aorta with a pseudocoarctation in the proximal portion (18-mm diameter) and tight stenosis in the mid-distal segment, with reduction of the vessel lumen to a few millimeters just above the celiac trunk (Fig. 1). The splanchnic arteries, the infrarenal aorta, and the renal and the iliac arteries, although severely hypoperfused, were all morphologically normal and free from calcifications.Preoperative blood chemistry showed no significant anomalies. Spirometry demonstrated mild-to-moderate restrictive lung function. Coronary angiography revealed no abnormalities of the coronary arteries, and aortography showed an 85emm Hg pressure gradient at the lower extremity of the restricted aorta. Total body positron emission tomography was performed to rule out focal inflammatory processes in the aorta, but it did not show any abnormal tracer distribution. Antibod...