Management of a Thoracic Aortic Coarctation Presenting as Severe Hypertension and Increasing Dyspnea on Exertion

BACKGROUND:
Adult thoracic aortic coarctation is universally fatal by the fifth decade if left untreated, primarily due to the accelerated arteriosclerosis. Repair of this rare thoracic pathology in adults presents several technical challenges due to thickness of the aortic wall, difficulties in aortic arch mobilization, large intercostal arteries, and post-stenotic aneurysm formation. There is a paucity of discussion of thoracic coarctation in the vascular literature; however, various repair approaches have been advocated in the cardiothoracic literature, including end-to-end anastomosis, path angioplasty repair, and subclavian-to-thoracic aorta bypass.
METHODS:
A morbidly obese (BMI 48) 35 year-old woman with hypertension, increasing buttock claudication to less than 50 feet, and dyspnea on exertion was referred to our center for evaluation of a recently found thoracic aortic coarctation. Despite being on four anti-hypertensive medications, the patient’s hypertension was poorly managed. A pressure gradient of > 110 mm Hg was present between the brachial and femoral arteries (210s vs, 100 mm Hg, respectively). CTA of the thorax/abdomen demonstrated the coarctation just distal to the left subclavian artery (Figure 1), a small abdominal aorta (<10 mm), and a large cohort of chest and abdominal wall collaterals, emanating from the subclavian to the internal mammary, thru the epigastric vessels into the common femoral arteries bilaterally. An endovascular management of the coarctation was deemed not safe due to the small size of the thoracic aorta (17 mm), small common iliac vessels (6 mm), and severe angulation of the thoracic aorta at the coarctation.
RESULTS:
Repair was done thru a left postero-lateral thoracotomy in the third rib interspace. After dividing the inferior pulmonary ligament, control was obtained in the aortic arch between the left carotid and subclavian arteries, at the left subclavian artery and in the mid-thoracic aorta. Because the patient had developed such large chest to abdominal wall collaterals, no adjunctive bypass procedure was used. Ligation of large intercostals in the area of the coarctation was necessary for complete vascular control; an interposition 16mm Dacron graft was used for repair (figure 2). The patient had an unremarkable post-operative recovery.
CONCLUSIONS:
Interposition graft repair of thoracic aortic coarctation helps avoid tension, which would be present in an end-to-end anastomosis, and is safe to perform in the adult patient without adjunctive bypass. As vascular surgeons become more facile with endovascular treatment of thoracic aortic aneurysmal disease, certain advantages of open repair for this rare thoracic aortic pathology may assume more importance in the future. Endovascular management with balloon dilatation with or without a covered self-expanding stent may palliate the hypertension but is limited in many cases by anatomical constraints and late recurrence; its greatest advantage may be in the treatment of recurrent stenosis or late, large aneurysm formation.