Coarctation of the Abdominal Aorta with Renal Arterial Stenosis

Coarctation of the Abdominal Aorta with RenalArterial Stenosis: Surgical Considerations

MICHAEL E. DE BAKEY, M.D., H. EDWARD GARRETr, M.D.,JIMMY F. HowELL, M.D., GEORGE C. MORmS, JR., M.D.

From the Cora and Webb Mading Department of Surgery, Baylor UniversityCollege of Medicine and the Methodist Hospital, Houston, Texas

COARCrATION of the aorta usually affectsthe thoracic aorta immediately proximal ordistal to the ligamentum arteriosum. Occa-sionally, however, it may occur in othersegments of the aorta and indeed at anysite along its whole course from the ascend-ing aorta to the terminal abdominal aorta.9'10,17, 20 Routine use of angiography in pa-tients with unexplained hypertension, mur-murs, and unequal blood pressure in thelower limbs has led to the diagnosis ofotherwise unrecognized aortic coarctationat unusual sites.

Until recently coarctation of the abdomi-nal aorta has been considered a relativelyrare lesion. In a review of the literature in1964, Bjork and Intonti5 were able to col-lect only 26 cases, of which 12 receivedtrials at surgical correction with survivaland improvement in nine. The followingyear Robicsek and associates19 were ableto find only 33 reported cases in additionto three cases of their own. It is apparent,however, that within recent years an in-creasing number of cases have been re-ported 18, 10-22 reflecting greater awarenessof the condition and the more widespreaduse of angiography for precise diagnosis.Wood23 has estimated that the abdominalaorta is affected in about two per cent ofall patients with aortic coarctation. The le-

Presented at the Annual Meeting of the South-em Surgical Association, December 6-8, 1966,Boca Raton, Florida.

This work was supported in part by the U. S.Public Health Service Grants HE-05435 and HE-03137, from the National Heart Institute.

sion may affect the entire abdominal aorta,including origins of the celiac, superiormesenteric, and renal arteries, or may belimited to the distal abdominal aorta with-out involvement of its major branches. As-sociated stenotic lesions of the renal ar-teries, which are not uncommon in ourexperience, account for the severe hyper-tension in these patients. Cardiac failure orcerebral hemorrhage eventually developsand is the major cause of death in patientswith untreated abdominal coarctation. Ourown experience with coarctation of the ab-dominal aorta during the past 13 years in-cludes a total of 26 cases, some of whichhave been reported in previous publica-tions.7 10,1 Of this number, 16 were asso-ciated with renal artery stenosis, and theobservations derived from our surgical ex-perience in their management provide thebasis for this report.

Clinical DataOf the 16 patients in this series, only four

were males. The ages of these patientsranged from 6 to 41 years, with the ma-jority occurring in the second decade of life(Fig. 1). All had had severe hypertension,which in most instances was recognized atan early age. Most of them complained ofheadache and fatigue after minimal exer-cise. All had received antihypertensivedrugs, but with poor control.

All patients had diminished blood pres-sure in the lower limbs. The intensity offemoral and pedal pulses was reduced inall the patients, but only one complained

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COARCTATION OF THE ABDOMINAL AORTA 831

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lishing the diagnosis but also a guide forappropriate surgical treatment.

Operative Technic

Surgical treatment of coarctation of theabdominal aorta depends on the site of thelesion, its relation to major visceral arteries,and the condition of the distal part of theabdominal aorta. Since 1952 when Glennand associates 14 performed a splenic arteryto aorta shunt in a patient with a coarctedsegment immediately above the celiac axis,various procedures have been advocated,including resection with grafting, bypassgrafts, and incision with angioplasty.1-5 7. 8,10, 11, 13-22 Resection of the stenosis withgrafting is feasible only in patients with a

short segmental coarctation at the level ofthe diaphragm or below the level of therenal arteries. Coarctation of the segment

of severe claudication. Although a loudmurmur could be heard on auscultation ofthe abdomen of all patients, physical evi-dence of collateral circulation was lacking.Ischemia of visceral organs or of the lowerlimbs is rarely, if ever, of clinical signifi-cance and has not been an important fea-ture of the disease in our experience.Roentgenograms of the chest and ab-

domen disclosed no significant abnormali-ties other than occasional left ventricularhypertrophy. Rib notching, enlarged aorticknob, and dilated left subclavian artery,commonly seen in patients with coarctationof the thoracic aorta, were absent. Arterio-grams were usually made by injectionthrough a catheter passed retrogradethrough the femoral and brachial arteries.Translumbar puncture of the aorta was

used in only one patient (Fig. 2). Arteriog-raphy not only provides a means of estab-

FIG. 1. Drawings ofthe lesions and surgicalcorrective procedures,with age and sex of 16patients with coarctationof the abdominal aortaassociated with renal ar-tery stenosis.

Volume 165Number S

DE BAKEY, GARRETT, HOWELL AND MORRIS Annals of SurgeryMay 1967

FIG. 2. (a) Drawingand (b) preoperative aor-togram showing extensivecoarctation of the ab-dominal aorta associatedwith severe stenosis ofboth renal arteries in a17-year-old white womanwith manifestations ofsevere hypertension. (c)Drawing showing methodof surgical correction con-sisting of bypass princi-ple using knitted Dacrongraft. (d) Aortogrammade postoperativelyshowing restoration ofnormal blood flowthrough bypass grafts toabdominal aorta and bothrenal arteries. Patient hasremained normotensivesince operation morethan five years ago andrecently delivered a nor-mal child. (Note arterialpressure determinationspreoperatively (a) show-ing marked gradient inboth renal arteries andelimination of the gradi-ent after operation (c).

between the celiac axis and renal arteriespresents the most difficult surgical prob-lem. Our experience would suggest that inthis type of lesion, and particularly whenassociated with renal artery stenosis, thebypass procedure is preferable, as evi-denced by the fact that it was employed inall but one of the cases.

The distal abdominal aorta is first ex-

posed through a midline abdominal in-cision, and the renal arteries are dissectedout and encircled with tapes (Fig. 3a).Pressures in the renal arteries are then com-

pared with pressures in the abdominalaorta proximal and distal to the coarcta-tion. A partial occluding clamp is applied

to the abdominal aorta along its left lateralside well below the distal extent of thecoarctation immediately above or belowthe origin of the inferior mesenteric arteryand the aorta is incised longitudinally (Fig.3b). A knitted Dacron tube graft is cutobliquely and attached to the incised wallof the aorta by end-to-side anastomosis(Fig. 3b). After completing this anasto-mosis, the distal thoracic aorta is exposedthrough a left anterior lateral incision atthe level of the seventh intercostal space.

The graft previously attached to the ab-dominal aorta is tunneled through theretroperitoneal space along the left gutterand brought up into the left pleural cavity

832

COARCTATION OF THE ABDOMINAL AORTA

through an opening in the diaphragm (Fig.3c). A partially occluding vascular clampis applied to the distal thoracic aorta im-mediately above the aortic hiatus, and theaorta is incised longitudinally. The Dacrontube graft is cut obliquely and attached tothe opening in the thoracic aorta by end-to-side anastomosis (Fig. 3d). Followingcompletion of this anastomosis the occlud-ing clamps are released, permitting bloodflow through the graft from the thoracicinto the abdominal aorta. Pressures in thethoracic aorta and abdominal aorta andrenal arteries are again compared. If thegradient in these arteries has been elimi-nated, no further revascularization proce-

dures are needed (Fig. 4). If, however, a

significant gradient (more than 10 mm.

Hg) persists between the abdominal aortaand renal arteries, bypass grafts to the af-

FIG. 3. Technic of op-erative procedure usingbypass principle withknitted Dacron tubes.

fected renal arteries are employed; eitherknitted Dacron tubes or autogenous saphe-nous vein is used, the latter is consideredpreferable in children. The grafts can origi-nate from the abdominal aorta (Fig. 5-7),the thoracoabdominal bypass graft (Fig.8), from both (Fig. 3, 9), or even fromthe thoracoabdominal bypass graft and thecommon iliac artery (Fig. 10), dependingon anatomic or technical factors facilitat-ing the procedure. Five milligrams of he-parin are injected into the renal artery,and vascular spring clamps are applied. Alongitudinal arteriotomy is then made, andthe graft is cut obliquely and sutured con-

tinuously end-to-side with a 5-0 linear poly-ethylene suture (Fig. 3e-g). Pressures are

again measured in the renal arteries to in-sure technically satisfactory anastomosis.The posterior peritoneum is closed with

Volume 165Number 5 833

DE BAKEY, GARRETT, HOWELL AND MORRIS

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continuous catgut. The thoracotomy andabdominal incisions are closed in standardfashion.When the coarctation is limited to the

abdominal aorta at or below the level ofthe renal arteries, an alternate method ofsurgical repair with patch graft angio-plasty may be used (Fig. 2d). In one ofour patients the abdominal coarctation was

Annals of SurgeryMay 1967

FIG. 4. (a) Drawingand (b) preoperative aor-togram showing coareta-tion in a 14-year-oldwhite girl with manifes-tations of severe hyper-tension (blood pressurein the upper extremitieswas 180/130), frontalheadaches and easy fati-gability. (c) Drawing and(d) postoperative aorto-gram showing method ofsurgical correction con-sisting of bypass graftfrom descending thoracicaorta above to abdominalaorta below coarcted seg-ment. At the time of op-eration, arterial pressurestudies (a) showed sig-nificant gradient betweenthoracic aorta above theabdominal aorta below.Similar gradient was pres-ent between the thoracicaorta and both renal ar-teries, as well as theaccessory renal arteries.Following completion ofbypass graft from tho-racic to abdominal aorta,the gradient previouslyfound in both the ab-dominal aorta and therenal arteries was elimi-nated (c).

repaired with a long Dacron patch and thestenosed segment of renal artery was by-passed with autogenous saphenous veingraft (Fig. 12).

Results

There were no operative or late deathsamong this group of 16 patients who hadsurgical correction of coarctation of the ab-

834


dominal aorta with renal arterial stenosis.In all but one patient, blood pressure ini-tially fell sharply to normal levels. The one

exception was a 7-year-old girl who re-

mained hypertensive after thoracoabdomi-nal bypass of the coarctation with side-to-side anastomosis of the left renal artery tothe thoracoabdominal bypass graft. Duringtwo months' observation after discharge,her blood pressure remained 200/145 mm.

FIG. 5. (a) Drawing

and (b) preoperativeaortogram in a 33-year-old white woman withmanifestations of easy fa- AORTM

tigability and severe hy- 'so-I AlAnpertension. (c) Drawing so60:showing methods of sur- ,40-gical correction using by- oo -

pass Dacron grafts. (d)Aortogram made after 40- INK ANTI

operation showing all 20- Igrafts functioning well -

and restoring normal cir-culation to abdominal A.

aorta as well as in bothrenal arteries. Arterialpressure measurementsmade during operationrevealed severe gradientacross both renal arteriesbut worse on the rightside in which there wascomplete occlusion of the (L

main right renal artery,but patency at its pri-mary branches. Patienthas remained asympto- C

matic and free of symp-toms for more than twoyears since operation.

Hg. Aortograms taken on readmissionshowed a normal right kidney with throm-bosis of the left renal artery. Left-sidednephrectomy resulted in reduction of theblood pressure to normal level. Only twoother patients required nephrectomy whichwas performed at the time of the primaryprocedure.

Renal function studies were performedin all patients before and after operation.

Volume 165Number 5 835


FIG. 6. (a) Drawingand (b) preoperativeaortogram showing co-arctation of the abdomi-nal aorta associated withsevere renal artery steno-sis in a 31-year-old whiteman. (c) Drawing show-ing method of surgicalcorrection using bypassprinciple with Dacrontubes. (d) Aortogrammade after operationshowing restoration ofnormal blood flowthrough bypass grafts toabdominal aorta andboth renal arteries. Pa-tient has remained asymp-tomatic and free ofsymptoms for more thantwo years since operation.

In general, the results of these studies re-

vealed values that were within normallimits or only slightly below normal beforeoperation with improvement in functionafter operation (Table 1). Follow up stud-ies including arteriography extending over

5 years are currently available on all pa-

tients (Fig. 2). They have all remainednormotensive and free of symptoms. Onepatient 5 years following operation had a

normal pregnancy and delivered a normalchild (Fig. 1, Case 1 and Fig. 2).

Discussion

Coarctation of the abdominal aorta withrenal artery stenosis is of clinical impor-

tance because of the associated severe hy-pertension which tends to progress andlead to fatal termination. In their reviewof the literature Bjork and Intonti found

TABLE 1. Pre- and Postoperative Renal Function Studiesof Patient uith Coarctation of thle Abdominal A orta

Associated uith Bilateral Renal ArteryStenosis

2 WeeksCase Number 3-20 yr. M. Pre-Op. Post-Op.

Creatinine clearanceml./min./1.73 M2 115 132

PSP Excretion- 7%15 min. 45 5830 min. 63 77

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Volume 165 COARCTATION OF T]Number 5

that in 14 cases not operated upon the av-erage age at death was 30 years. The con-dition is probably of congenital origin inthe majority of cases as suggested by thehistory of hypertension at an early age andthe youthfulness of our patients at the timeof treatment. Pathologic tissue for studywas available in only a few instances sincethe bypass procedure was employed inmost cases, and these observations pro-vided no additional information as topathogenesis and etiology than has beenpreviously reported. In general, the charac-teristic pathologic features consisted of in-creased density of surrounding connectivetissue, marked intimal proliferation withaccumulation of elastic and collagenoustissue in the region of the media.Although the lesion tends to assume a

FIG. 7. (a) Drawingand (b) preoperativeaortogram in a 13-year-old white boy with mani-festations of severe hy-pertension and easy fa-

stigability. (c) Drawing t60showing method of surgi- I20cal correction using by- °JV N\Jipass Dacron tubes and -0 R;LAE T(d) and (e) postopera- 4/tive aortograms showing 20-restoration of normal cir- Aculation through grafts.Arterial pressure deter-minations during opera-tion (a) showed severegradient between thora-cic and abdominal aorta -and between abdominalaorta and left renal ar-tery, but no gradient be-tween abdominal aortaand right renal artery.Following completion ofbypass grafts no gradientwas found between ab- iidominal aorta and renal so -larteries (c) L4 OT

'HE ABDOMINAL AORTA 837fairly characteristic pattern, some varia-tions exist in the nature and extent of thecoarcted segment as well as in its involve-ment of the major visceral branches of theabdominal aorta, particularly the renal ar-teries. In the majority of cases the coarctedsegment is fairly sharply defined arisingimmediately above or below the celiac axisand usually terminating just above theorigin of the inferior mesenteric artery.While some degree of involvement of theceliac and superior mesenteric arteries maybe apparent from arteriographic studies inmost of our cases pressure measurementsmade at operation in these arteries re-vealed little or no significant gradient andin none of the patients was it found neces-sary to perform restorative vascular sur-gery on these arteries. The most distinctive

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FIG. 8. (a) Drawingand (b) preoperativeaortogram in a 20-year-old white man withmanifestations of severehypertension in upperextremities (blood pres-sure 220/140) and di-minished blood pressurein lower extremities(150/90), easy fatigabil-ity, and headaches. (c)Drawing showing methodof surgical correctionwith Dacron bypassgrafts. (d) Aortogramshowing restoration ofnormal circulation to ab-dominal aorta and bothrenal arteries. Patient hassince remained normo-tensive and asymptomaticsince operation threeyears ago.

feature of this pattern of the disease is thetendency of the coarcted segment to in-volve the origin of the renal arteries. Steno-sis of the renal arteries is usually limitedsharply to the ostia and only infrequentlyextends more than a few millimeters be-yond this point. Thus in most cases themain renal artery distal to the ostia is rela-tively normal or may suggest post stenoticdilatation (Fig. 2, 7). Even in cases inwhich complete occlusion of the renal ar-

tery has occurred in the region of the ostiait may be found patent at the level of itsprimary branches (Fig. 5). Bilateral in-volvement of the renal arteries is morecommonly encountered than unilateral in-volvement as evidenced by the fact that

the former type of occurrence was found in11 of our 16 cases.

Although in most of our cases preopera-tive renal function studies showed valuesthat were within lower normal ranges or

only slightly reduced, such studies may beparticularly significant in cases in whichrevascularization of one kidney may not bepossible and it becomes necessary to con-sider nephrectomy (Fig. 1, Cases 9 and 10,and Fig. 11). In our experience, arterialpressure determinations at the time of op-eration have been found especially usefulin assessing the significance of stenotic le-sions and as a guide to surgical therapy.This may be exemplified by our experiencewith certain cases (not included in this se-

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Volume 165 COARCTATION OF TINumber 5

ries of 16 patients) in which it was not pos-sible to determine preoperatively from bothrenal function and arteriographic studieswhether or not there was significant steno-sis of the renal arteries. At operation it wasfound that a significant pressure gradientwas present between the descending tho-racic aorta above the coarcted segment and

FIG. 9. (a) Drawingand (b) preoperativeaortogram showing co-arctation of the abdomi-nal aorta associated withrenal artery stenosis in a20-year-old white womanwith manifestations of se-vere hypertension, head-aches, easy fatigability,and some intermittent Aclaudication of the lowerextremities. (c) Drawingshowing method of surgi-cal correction using by-pass graft principle. (d)Aortogram made afteroperation showing resto-ration of normal bloodflow to abdominal aorta . - -and both renal arteries.Patient has remainedasymptomatic and free ofsymptoms - since opera-tion.

'HE ABDOMINAL AORTA 839

the abdominal aorta below this segment, aswell as the renal arteries. Following the at-tachment of a thoracoabdominal bypassgraft, this gradient was eliminated in boththe abdominal aorta and renal arteries,thus precluding the need for additional re-vascularization procedures (Fig. 4). Suchstudies have proved similarly useful in pa-

840 DE BAKEY, GARRETT, HOWELL AND MORRIS

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tients with unilateral involvement of therenal arteries (Fig. 7). Moreover, they alsoserve as a good criterion of the efficacy ofthe revascularization procedure since theelimination of a pressure gradient indicatesrestoration of normal blood flow (Fig. 2,5, 8, 10).

Finally, certain considerations of the op-erative procedure deserve comment. As re-

gards exposure, we believe that separate

Annals of SurgeryMay 1967

FIG. 10. (a) Drawingand (b) preoperativeaortogram showing ex-tensive coarctation of theabdominal aorta associ-ated with bilateral renalartery stenosis in a 41-year-old white womanwith severe hypertension.(c) Drawing showingmethod of surgical cor-rection. Because the co-arcted segment extendeddistally to just above thebifurcation of the ab-dominal aorta, it wasnecessary to attach thedistal end of the thoraco-abdominal bypass graftto the abdominal aorta atthe level of the bifurca-tion itself, extendingpartly into the left com-mon iliac artery. For thesame reason, it wasfound preferable to at-tach the proximal anasto-mosis of the right bypassgraft to the right renalartery to the right com-mon iliac artery. (d)Aortogram made afteroperation showing resto-ration of normal bloodflow to abdominal aortaand both renal arteriesthrough the bypass grafts.

midline abdominial incisions and left tho-racotomy is preferable to the use of a tho-racoabdominal approach since the formerprovides adequate exposure and is lesstraumatic. Although various types of re-

vascularization procedures have been em-

ployed, our experience would now suggestthat the bypass principle using knittedDacron tubes is by far the most satisfac-tory and efficacious. It has the great advan-

0-.mmH.

Volume 165Number 5

FIG. 11. Drawing il-lustrating surgical methodof repair of coarctationof abdominal aorta bymeans of patch graft an-gioplasty using knittedDacron and bypass graftto left renal artery usingautogenous saphenousvein.


..;

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tages of flexibility and ease of applicationunder varying anatomic circumstances andof minimizing surgical trauma and durationof the operative procedure. The readyadaptations in the application of the by-pass principle depending upon varyinganatomic circumstances are well illustratedin this series of cases. Good evidence of theefficacy of this method of surgical treat-ment is provided by the highly successfulimmediate and long-term results in therestoration and maintenance of normalfunction.

Summary1. This report is concerned with an

analysis of our experience with 16 patientswith coarctation of the abdominal aortaand associated renal arterial stenosis. Se-vere hypertension was the prominent clini-cal sign in all the patients. Ischemia ofvisceral organs or the lower limbs was notsignificant.

2. The ages of these patients rangedfrom 6 to 41 years, with the majority oc-

curring in the second decade of life. Thefemale sex predominated in a ratio of threeto one.

841

DE BAKEY, GARRETT, HOWELL AND MORRIS Annals of Surgery.May 1967

FIG. 12. (a) Drawingand (b) preoperativeaortogram in a 20-year-old white woman show-ing severe coarctation ofthe abdominal aorta aris-ing at the level of therenal arteries, and pro-ducing severe stenosis ofthe left renal artery andcomplete occlusion of theright renal artery. (c)Drawing showing methodof surgical treatmentusing patch graft angi-oplasty as illustrated inFigure 11 with autoge-nous saphenous vein by-pass graft from abdomi-nal aorta to left renal ar-tery. The right renal ar-tery was found to becompletely occluded andsince preoperative studiesshowed no function inthe right kidney and be-cause at operation theright kidney was foundto be constricted andatrophic, it was removed.(d) Aortogram made af-ter operation showingrestoration of normalblood flow through ab-dominal aorta and intoleft renal artery.

3. The diagnosis may be suggested bycertain clinical manifestations includingparticularly the presence of severe hyper-tension in a relatively young individual, re-

duced pulses and blood pressure in thelower extremities, murmurs in the abdomenor lumbar region and absence of the char-acteristic clinical and radiologic signs ofthe more common forms of isthmic coarc-

tation of the thoracic aorta. Arteriography,however, is essential not only to establishthe diagnosis but also to provide a guide tosurgical therapy.

4. Coarctation of the abdominal aortaassociated with renal artery stenosis tendsto assume a characteristic pattern. Whilesome variations exist in the nature and ex-

tent of the coarcted segment, in the ma-

jority of cases the stenosis begins at or justabove the diaphragmatic hiatus and termi-nates above the origin of the inferior mes-

enteric artery. Bilateral involvement of therenal arteries is common and occurred in11 of the 16 cases in this series.

5. The operative procedure used in allpatients in this series except one consisted

842

Volume 165 COARCTATION OF THE ABDOMINAL AORTA 843Number 5

of a bypass graft using knitted Dacrontubes with end-to-side anastomosis fromthe descending thoracic aorta above thecoarcted segment to the abdominal aortabelow this segment with similar bypassgrafts from the thoracoabdominal bypassgraft or from the abdominal aorta to therenal arteries. This method of surgicaltreatment is considered the most satisfac-tory and efficacious as evidenced by thehighly gratifying results.

6. There were no immediate or latedeaths in this series. Follow up studiescurrently available on all the patients ex-tending for periods over five years showthat all have remained normotensive andfree of symptoms.

References

1. Albanese, A. R. and Baila, M. R.: CoarctationCongenita de la Aorta Abdominal. Bol. ytrab. Acad. Argent. cir., 37:211, 1952.

2. Albanese, A. R. and Lazzarine, A. A.: Coarc-tation of the Abdominal Aorta Graft of Pre-served Aorta. Angiology, 4:429, 1953.

3. Baird, R. J., Evans, J. R. and Labrusse, C. L.:Coarctation of the Abdominal Aorta. Arch.Surg., 89:466, 1964.

4. Beattie, E. J., Jr., Cooke, F. N., Paul, J. S.and Orbison, J. A.: Coarctation of Aorta atLevel of Diaphragm Treated Successfullywith Preserved Human Blood Vessel Graft.J. Thorac. Surg., 21:506, 1951.

5. Bjork, V. 0. and Intonti, F.: Coarctation ofAbdominal Aorta with Right Renal ArteryStenosis. Ann. Surg., 160:54, 1964.

6. Brust, A. A., Howard, J. M., Bryant, M. R.and Godwin, J. T.: Coarctation of the Ab-dominal Aorta with Stenosis of the RenalArteries and Hypertension. Amer. J. Med.,27:793, 1959.

7. Cooley, D. A. and De Bakey, M. E.: Resectionof Thoracic Aorta with Replacement byHomograft for Aneurysms and ConstrictiveLesions. J. Thorac. Surg., 29:216, 1955.

8. D'Abreu, A. L., Rob, C. G. and Vollmar, J. F.:Die Coarctatio Aortae Abdominalis. Langen-becks Arch. klin. Chir., 290:52, 1959.

9. De Bakey, M. E. and Beall, A. C., Jr.: Suc-cessful Surgical Correction of SupravalvularAortic Stenosis. Circulation, 27:858, 1963.

10. De Bakey, M. E.: Basic Concepts of Therapyin Arterial Disease. Bull. of N. Y. Acad.Med., 39:704-749, 1963; JAMA, 186:484,1963.

11. Dillon, M. L. and Postlethwait, R. W.: Coarc-tation of the Abdominal Aorta. Report of aCase and Review of the Surgical Procedures.Southern Med. J., 54:295, 1961.

12. Fisher, E. R. and Corcoran, A. C.: CongenitalCoarctation of Abdominal Aorta with Re-sultant Renal Hypertension. Arch. Int. Med.,89:943, 1952.

13. Gerbasi, F. S., Kibler, R. S. and Margileth,M.: Coarctation of the Abdominal Aorta-A Case Successfully Surgically Treated. J.Pediat., 52:191, 1958.

14. Glenn, F., Keefer, E. B. C., Speer, D. S. andDotter, C. T.: Coarctation of the LowerThoracic and Abdominal Aorta ImmediatelyProximal to the Celiac Axis. Surg. Gynec.Obstet., 94:561, 1952.

15. Hansson, J., Ikkos, D., Johansson, L, Rudhe,U. and Senning, A.: Coarctation of Abdomi-nal Aorta, Case Report and Description ofSuccessful Surgical Treatment. Acta Chir.Scand. Suppl., 245:315, 1959.

16. Milloy, F. and Fell, E. H.: Elongate Coarcta-tion of the Aorta. Arch. Surg., 78:759, 1959.

17. Morris, G. C., Jr., De Bakey, M. E., Cooley,D. A. and Crawford, E. S.: Subisthmic Aor-tic Stenosis and Occlusive Disease. Arch.Surg., 80:87, 1960.

18. Pyorala, K., Heinoneu, O., Doskelo, P. andHeikel, P. E.: Coarctation of the Abdomi-nal Aorta. Review of Twenty-Seven Cases.Amer. J. Cardiol., 6:650, 1960.

19. Robicsek, F., Sanger, P. W. and Daughtery,H. K.: Coarctation of the Abdominal AortaDiagnosed by Aortography: Report of ThreeCases. Ann. Surg., 162:227, 1965.

20. Senning, A. and Johansson, L.: Coarctation ofthe Abdominal Aorta. J. Thorac. Cardiov.Surg., 40:517, 1960.

21. Sondergaard, T. and Ottosen, P.: Coarctationof the Abdominal Aorta. Acta Chir. Scand.Suppl., 283:194, 1961.

22. Stokes, J. M., Wohltmann, H. and Carlsson,E.: Coarctation of the Abdominal Aorta andRenal Artery Stenosis Corrected by SurgicalTreatment. Ann. Surg., 152:856, 1960.

23. Wood, P.: Diseases of the Heart and Circula-tion. 2nd Ed. London, Eyre and Spottis-woode, 1956, pp. 328-343.

Documents

Coarctation of the Abdominal Aorta with Renal Arterial Stenosis