Location
LSU Health Sciences Center - New Orleans
Event Website
https://digitalscholar.lsuhsc.edu/surgery_s/
Document Type
Event
Start Date
4-5-2023 8:50 AM
End Date
4-5-2023 9:00 AM
Description
Introduction: Aortoiliac Occlusive Disease is a variant of peripheral artery disease defined as atherosclerotic occlusion of the abdominal aorta, renal arteries, and iliac arteries. It has long been associated with symptoms such as claudication, impotence, and diminished distal pulses. Many of the long-term side effects associated with this disease are a result of chronic obstruction of blood flow to distal organs and peripheral vasculature. Atherosclerosis has been well studied in medical literature for decades, however, little information is present exploring the pathogenesis of complete large-vessel occlusion and its subsequent complications.
Case Description: This report centers on the case of a 39-year-old male w/ history of recently diagnosed heart failure with reduced EF (45-50%) and CKD stage IV presenting with complaints of chest pain, shortness of breath, and lower extremity edema. Physical exam on admission was notable for pulmonary crackles, S3 gallop, lower extremity pitting edema, and dopplerable monophasic dorsalis pedis pulses bilaterally. He was initially diagnosed with acute exacerbation of heart failure and subsequently diuresed with symptomatic improvement. While admitted, patient was noted to have refractory hypertension despite numerous (>7) antihypertensive agents. Secondary causes of hypertension were pursued and ultimately negative for pheochromocytoma, Cushing's. Hyperaldosteronism workup was deferred given the need for washout due to recent Aldactone use. Notably, renal duplex ultrasound showed right renal artery stenosis. Follow-up CT Angiogram demonstrated complete abdominal aortic occlusion at the level the renal arteries with high-grade renal artery stenoses bilaterally. Treponema testing was negative and clinical history was not consistent with large vessel vasculitis. Ultimately, the possibility of a previous aortic dissection leading to scarring and subsequent occlusion was decided upon after correlation of clinical history and imaging findings. This etiology has been difficult to confirm given the acuity of presentation. He underwent successful aortic interposition bypass with right renal endarterectomy shortly thereafter. Post-operatively, he has demonstrated continued improvement in renal function and systolic pressures.
Discussion: The purpose of this report is to explore the literature regarding acute and chronic etiologies of complete aortoiliac occlusion and how they relate to renal artery stenosis and malignant hypertension. It also draws attention to the severity of atherosclerotic disease that can be present in young patients with Aortoiliac Occlusive Disease that present with and without exposure to certain risk factors. This case highlights the significance of a thorough evaluation when it comes to secondary hypertensive workup.
Recommended Citation
Lachute, Courtney; Mercante, Andrew; and Miles, Lauren, "Aortoiliac Occlusive Disease and Refractory Malignant Hypertension: A Case Report" (2023). Surgery Research Symposium. 6.
https://digitalscholar.lsuhsc.edu/surgery_s/2023/postera/6
Aortoiliac Occlusive Disease and Refractory Malignant Hypertension: A Case Report
LSU Health Sciences Center - New Orleans
Introduction: Aortoiliac Occlusive Disease is a variant of peripheral artery disease defined as atherosclerotic occlusion of the abdominal aorta, renal arteries, and iliac arteries. It has long been associated with symptoms such as claudication, impotence, and diminished distal pulses. Many of the long-term side effects associated with this disease are a result of chronic obstruction of blood flow to distal organs and peripheral vasculature. Atherosclerosis has been well studied in medical literature for decades, however, little information is present exploring the pathogenesis of complete large-vessel occlusion and its subsequent complications.
Case Description: This report centers on the case of a 39-year-old male w/ history of recently diagnosed heart failure with reduced EF (45-50%) and CKD stage IV presenting with complaints of chest pain, shortness of breath, and lower extremity edema. Physical exam on admission was notable for pulmonary crackles, S3 gallop, lower extremity pitting edema, and dopplerable monophasic dorsalis pedis pulses bilaterally. He was initially diagnosed with acute exacerbation of heart failure and subsequently diuresed with symptomatic improvement. While admitted, patient was noted to have refractory hypertension despite numerous (>7) antihypertensive agents. Secondary causes of hypertension were pursued and ultimately negative for pheochromocytoma, Cushing's. Hyperaldosteronism workup was deferred given the need for washout due to recent Aldactone use. Notably, renal duplex ultrasound showed right renal artery stenosis. Follow-up CT Angiogram demonstrated complete abdominal aortic occlusion at the level the renal arteries with high-grade renal artery stenoses bilaterally. Treponema testing was negative and clinical history was not consistent with large vessel vasculitis. Ultimately, the possibility of a previous aortic dissection leading to scarring and subsequent occlusion was decided upon after correlation of clinical history and imaging findings. This etiology has been difficult to confirm given the acuity of presentation. He underwent successful aortic interposition bypass with right renal endarterectomy shortly thereafter. Post-operatively, he has demonstrated continued improvement in renal function and systolic pressures.
Discussion: The purpose of this report is to explore the literature regarding acute and chronic etiologies of complete aortoiliac occlusion and how they relate to renal artery stenosis and malignant hypertension. It also draws attention to the severity of atherosclerotic disease that can be present in young patients with Aortoiliac Occlusive Disease that present with and without exposure to certain risk factors. This case highlights the significance of a thorough evaluation when it comes to secondary hypertensive workup.
https://digitalscholar.lsuhsc.edu/surgery_s/2023/postera/6