Introduction
Coarctation of the aorta (CoA) is a congenital defect that may lead to long-term cardiovascular complications, even after successful surgical or interventional repair. Among these complications, aneurysmal dilatation is typically a late finding associated with prior procedures. Pre-intervention aneurysm formation is exceedingly rare and poses a unique management challenge. This case report describes a paediatric patient with coarctation of the aorta and a giant aneurysm diagnosed before any surgical or catheter-based treatment.
Case presentation
An 11 year-old male, that a year ago began with pain in both lower extremities of moderate intensity, hypodynamia and weight loss, within the approach they auscultated a murmur, in the last month, the patient presented with a history of severe holocranial headache, at that event it was reported with sitolic blood pressures of up to 200 mmHg, so he was treated with amlodipine and nifedipine and was referred to our institution for further evaluation. The physical examination reveals blood pressure gradient in extremities:
Right upper extremity: 153/86 mm Hg. Left upper extremity: 120/78 mm Hg.
Right lower extremity: 104/74 mm Hg. Left lower extremity: 102/71 mm Hg.
Left aortic arch was evaluated with echocardiogram and CT scan proximal transverse arch measuring 12.8 mm (ZS-1.52), a preductal coarctation area is observed at the level of the distal transverse arch with a diameter of 4.5 mm (ZS-8.4), with a maximum gradient of 124 mmHg, with post-coarctation dilatation of the descending aorta. The origin of the left subclavian artery is observed posterior to the coarctation. As shown in Figure 1a and 1b.
( a ) and ( b ) Site of coarctation and large aneurysm after the left subclavian artery emerges, shown in left anterior oblique and anteroposterior projections, respectively.
Given the presence of the aneurysm prior to any intervention, an evaluation for vasculitis was conducted. Rheumatologic assessment, including application of the Ishikawa diagnostic criteria, ruled out Takayasu’s arteritis.
The case was then reassessed by the interventional cardiology team, who opted for cardiac catheterisation. A covered stent was successfully deployed across the coarcted and aneurysmal segment of the aorta. Post-procedural angiography confirmed excellent stent positioning, complete exclusion of the aneurysm, and resolution of the pressure gradient. As shown in Figure 2a and 2b.
( a ) and ( b ) Post-procedure angiography, that shows the origin of the left subclavian artery occluded by the covered stent, neither coarctation nor aneurysm, in left anterior oblique and anteroposterior projections, respectively.
The patient was discharged 24 hours later on captopril therapy. Follow-up imaging demonstrated sustained stent patency, no residual gradient, and no evidence of aneurysmal recurrence.
Discussion
Aneurysm formation is a recognised but infrequent complication following surgical or catheter-based treatment of aortic coarctation. Reference Toro-Salazar, Steinberger and Thomas1 However, primary aneurysmal dilatation prior to any intervention is extremely rare and poorly documented in the literature.
The aetiology of such aneurysms in untreated aortic coartaction remains unclear, but may involve focal degeneration of medial layer of the aorta, increasing prestenotic pressure, or by localised inflammation. In this case, inflammatory causes were excluded, and the aneurysm was presumed to be congenital or haemodynamically induced.
Covered stent placement has emerged as a safe and effective approach in managing aneurysms coarctation-associated, particularly when aneurysmal involvement is identified preoperatively. In paediatric populations, long-term follow-up is essential to monitor for stent integrity and aneurysm recurrence.
Conclusion
This case underscores the importance of a rare but clinically significant presentation of preprocedural aneurysmal dilatation in a child with aortic coarctation. Early recognition and prompt interventional management with covered stenting resulted in a favourable outcome. Awareness of such presentations is crucial to prevent catastrophic vascular complications.
