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“Coral reef” atherosclerosis of the suprarenal aorta

1986; Elsevier BV; Volume: 3; Issue: 4 Linguagem: Inglês

10.1016/0741-5214(86)90305-8

1097-6809

David Chas. Schechter,

Cardiac, Anesthesia and Surgical Outcomes

The variety of aortic atherosclerosis that appears with dominant suprarenal segmental obstruction fortunately is rare. Although the technical problems of operating on that type of aorta were mentioned a couple of decades ago,1Starzl TE Trippel OH Reno-mesentero-aorto-iliac thrombo-endarterectomy in patient with malignant hypertension.Surgery. 1959; 46: 556-564PubMed Google Scholar, 2Bergan JJ Trippel OH Management of juxtarenal aortic occlusions.Arch Surg. 1963; 87: 230-238Crossref PubMed Scopus (23) Google Scholar the excellent article by Qvarfordt et al.3Qvarfordt PG Reilly LM Sedwitz MM Ehrenfeld WK Stoney RJ “Coral reef” atherosclerosis of the suprarenal aorta: A unique clinical entity.J Vasc Surg. 1984; 1: 903-908Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar firmly places the subject in a surgical context. Their choice of a neologism, “coral reef,” to designate the principal suprarenal concretion is apt, as will be readily confirmed by anyone who has had to cope with the lesion. For those of us who sail, the term vividly evokes the image of submerged perils from which to steer clear away. As far as I am aware, the earliest description and graphic depiction of this entity were in a postmortem narrative published in 1727. This, for several reasons, is a remarkable document. It appeared in the posthumous edition of a landmark textbook in medical literature, that by Johann Jakob Wepfer4Wepfer B, Wepfer GM. Memoria Wepferiana. In: Wepfer JJ. Observationes medico-practicae, de affectibus capitis internis & externis. JA Ziegler, 1727.Google Scholar on diseases of the head (Fig. 1).Wepfer, a Swiss, was one of the most celebrated anatomists of the seventeenth century. He traced the course of the vascular system of the brain, including the circular anastomosis to which Willis' name was subsequently attached. He disproved the existence in human beings of the “retemirabile,” or vessel filtration apparatus alleged since preGalenic days to function in the brain. He demonstrated that certain kinds of cerebral hemorrhage derived from rupture of small aneurysms. Wepfer died of heart failure on Jan. 28, 1695 at the age of 75 years. Autopsy was performed within a few hours in the presence of relatives and was officiated by “the Clarissimus Dr. D. Pfister, a most skilled doctor of medicine and surgery.” The findings were reported in extenso, together with a comprehensive sketch of Wepfer's life, travels, positions, honors, and the circumstances of his final sickness in a Memoria Wepferiana that prefaced the edition of his book 32 years later. The reason for that great delay is a mystery. Perhaps Wepfer's family saw fit to record for posterity their kinsman's aortic pathology after the appearance in 1723 of Stentzel's dissertation5Stentzel CG De steatomatibus aortae (1723). Reproduced.in: Disputationes ad morborum historiam et curationem facientes. II. : MM Bousquet, Lausanne1757: 529-562Google Scholar on calcified “steatomatous” obstructions of the thoracic aorta. The following is a translation of the section in the Memoria that treats of Wepfer's “coral reef” atherosclerosis:At the base of the heart, near the pulmonic artery, bony substance was encountered on section. The aortic cusps had rough ossifications, hurtful to the fingers, so prominently dagger-like were they in sharpness. Thence, everywhere, all the way to the very iliac ramifications themselves, were deposits of semi-circular shape whose consistency varied from gristle to frank bone. Near the renal arteries a flat patch of bone, one-twelfth the breadth of the aorta, was embedded. Especially conspicuous were hard bony mounds in the long axis of the iliacs and beyond which narrowed these structures. With strong scissors the aorta was carefully freed from its coverings so as to better inspect the interior thoroughly. Where otherwise the native blood passage would be lustrous and smooth, at that place near the celiac it was almost obliterated round about by horrid, uneven, scabrous protuberances of bone, difficult to cut. The internal coat towards the renals was disrupted and lacerated; to such an extent was its fabric shattered and of salient dark color there that one would fear it on the verge of rupturing....The illustration best portrays the excrescence and erosion at this site and all the other parts too, and serves to indicate that similar aortic ossification of such great magnitude in a septuagenarian has hitherto not been recounted.4Wepfer B, Wepfer GM. Memoria Wepferiana. In: Wepfer JJ. Observationes medico-practicae, de affectibus capitis internis & externis. JA Ziegler, 1727.Google Scholar Scaphusii:**Present-day Schafthausen (Germany).