Obstruction of the Abdominal Aorta Above the Level of the Renal Arteries

Obstruction of the abdominal aorta is an almost commonplace diagnosis today. Most of the cases reported in the literature occur in the lower aorta, particularly at the bifurcation (3). There have been many examples of aortic occlusion at the level of the renal arteries, but in most instances these were secondary to a “Leriche“ type of atherosclerotic aortic occlusion (8), or they were due to syphilis (5) or coarctation (7, 9). The occlusion to be reported in this presentation was situated in the abdominal aorta above the renal arteries. A careful review of the literature failed to reveal a counterpart or a radiologic study of any other suprarenal atherosclerotic occlusive lesion. Baylin (2) and Ross and Mc-Kusick (12) described two cases which have certain resemblances to ours, but apparently no radiographs were obtained since the findings were discovered only during the autopsy examination. Case History J. C., a 45-year-old white male executive, was referred to Strong Memorial Hospital on Dec. 2, 1962, with a clinical diagnosis of “coarctation of the aorta.” Nineteen years earlier, when the patient was twenty-six, hypertension was first discovered during a clinical examination without, apparently, any related significant symptoms or signs. At that time he had been returned from the Far East, during World War II, for treatment of malaria. In 1958, severe hypertension and the first roentgen evidence of a calcified plaque at the junction of the thoracic and abdominal aorta were noted in another institution. Surgery was refused by the patient, hence aortography was not performed. The patient was able to lead an active life and work hard until 1960, when transient cerebrovascular accidents as well as myocardial infarctions began to complicate the clinical picture. At physical examination, the pertinent findings were: blood pressure of 230/130 mm. Hg in both arms; absent pulses in the femoral, popliteal, and dorsal pedal arteries; pulse rate of 80 per minute, and cardiomegaly. During the period of hospitalization the patient's temperature remained about 37° C. Blood electrolytes and blood-urea-nitrogen measurements were within normal limits. Total blood serum cholesterol measured 370 mg. per cent and blood creatinine 2.2 mg. per cent. Urinalyses showed occasional casts (?), no red blood cells, a nonfixed specific gravity, and no albumin. Chest roentgenograms revealed a markedly enlarged heart. The thoracic aorta was moderately widened and the aortic arch quite prominent. 1 No intracardiac calcifications were present. Bilateral lower rib notchings along their inferior margins were visualized best in the abdominal films. Multiple abdominal radiographs (Fig. 1) demonstrated smoothly marginated, dense calcification which occupied the lumen of the aorta from the level of the eleventh thoracic vertebra to the upper border of the second lumbar vertebra. The thoracic aorta was moderately dilated but no signs of aneurysm were present.