Revascularization with the branched graft in middle aortic syndrome

A case of middle aortic syndrome which was thought to be the thoracoabdominal type of Takayasu's disease was successfully treated with the branched graft bypass. Patient was a 23 year-old woman with hypertension and abdominal pain. The preoperative angiography revealed aortic stenosis from the celiac axis to the left renal artery. The operative procedures were as follows; patient was positioned in supine with her left shoulder and arm raised. Eighth intercostal thoracotomy and midline laparotomy was performed with the thoracoabdominal incision. The branched graft was made previously with woven Dacron (phi 18 mm) and three EPTFEs (phi 8mm). The woven Dacron of the graft was used for the bypass from the descending thoracic aorta to the infrarenal abdominal aorta, and the branched EPTFEs of the graft were used for the bypasses to the common hepatic artery, the superior mesenteric artery and the right renal artery in this order. The bypasses were placed along the anatomical courses in the retroperitoneal space. Postoperatively, the blood pressure dropped and the abdominal pain disappeared. The plasma renin activity decreased and the renal function improved. Two months after operation the bypasses were patent by the angiography and now six months after operation she has returned to her social life healthily. The approach to the aorta and its abdominal branches by thoracotomy and laparotomy and bypass with the three branched graft was useful for middle aortic syndrome.