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

Abstract

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.

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

“…Given that the former 2 options necessitate cardiopulmonary bypassing under extensive incisions, the extra-anatomic bypass has been regarded as the most feasible option. 5 , 8 Extra-anatomic bypassing in the treatment of mid-aortic syndrome has been reported as safe and effective for relieving critical ischemic symptoms; however, bypassing between peripheral vessels (ie, axillofemoral) has a limitation of poor long-term graft patency, whereas central bypassing (ie, ascending aorta as the inflow source) usually requires extensive incisions both in the chest and the abdomen.…”

“…With poorer long-term graft patency observed in peripheral bypassing compared with central bypassing, which is explained by the suboptimal inflow source, central bypassing has been suggested as the ideal option to treat this grave disease. 5 , 6 , 7 , 8 Despite the favorable long-term graft patency, the major limitation of this central bypassing is a need for extensive surgical incisions of combining sternotomy and laparotomy, 5 which hinder its use in clinical practice.…”

Open repair of long-segment aortic atresia complicated by uncontrolled hypertension

“…In the presence of additional cardiac lesions warranting concomitant intervention, Yamamoto and colleagues 5 demonstrated the flexibility of aortoaortic bypass in their series of 6 patients with MAS. In 1 patient requiring concomitant coronary artery bypass grafting and aortic root replacement, they performed ascending abdominal aortic bypass via median sternotomy, providing necessary exposure for the additional components of the operation.…”