Asymptomatic aortic coarctation diagnosed because of a vast calcified collateral circulation

A 62-year-old man came to the emergency department reporting mild chest pain that was similar to pain he had experienced 18 years before when he suffered a myocardial infarction. An electrocardiogram and cardiac biomarkers did not show any signs of an acute coronary syndrome; he was therefore admitted to the cardiology department for further studies. A chest X-ray revealed two round structures that were initially interpreted as calcified nodules (Panel A). Stress echocardiography was undertaken, which demonstrated no evidence of myocardial ischemia but did indicate a coarctation of the distal aortic isthmus with a peak to peak gradient of 8 mmHg. To confirm this finding, computed tomographic angiography (CTA; Panel B) and magnetic resonance angiography (MRA; Panel C) were done, showing a significant aortic coarctation. There was an extensive collateral circulation, which was one of the reasons for the low pressure gradient. The CTA also demonstrated a calcified, 30-mm bilobed pseudoaneurysm with its origin in a branch of the left subclavian artery, corresponding to the calcified structure on the chest X-ray (arrows). Additional tests were performed in order to exclude related vascular complications, including binocular indirect ophthalmoscopy and magnetic resonance angiography of the vessels of the neck and head, both of which were unremarkable. At the time of diagnosis, the patient refused any kind of intervention. He continued on beta-blockers and additional antihypertensive drugs and is being followed by cardiologists and vascular surgeons. The ACC/AHA Guidelines ¹ recommend treating aortic coarctation when the translesional gradient is > 20 mmHg or when there is evidence of significant collateral flow at the time of diagnosis in older patients. The endovascular-first approach is now accepted in adults with aortic coarctation, as it is a safe technique with a low rate of complications.^2,3

Panel A Panel B Panel C

‘Images in vascular medicine’ is a regular feature of Vascular Medicine. Readers may submit original, unpublished images related to clinical vascular medicine. Submissions may be sent to: Mark A Creager, Editor in Chief, Vascular Medicine, via the web-based submission system at http://mc.manuscriptcentral.com/vascular-medicine