A 56-year-old man with coarctation of the aorta with refractory
hypertension
Coarctation of the aorta
Jianying Deng, M.D.
Department of Cardiovascular Surgery,Chongqing Kanghua Zhonglian
Cardiovascular Hospital,
Chongqing 400015, China
Correspondence: Jianying Deng, Department Of Cardiovascular
Surgery,Chongqing Kanghua Zhonglian Cardiovascular Hospital, No. 168,
Haier Road, District of Jiang Bei, Chongqing 400015, China. e-mail:
65673171@qq.com
Abstract A 56-year-old man was admitted to our hospital for a
complain of headache with a history of one week. He had a history of
hypertension for more than 30 years, but his blood pressure was not well
controlled with medication. After admission, it was found that his blood
pressure of the lower limbs was obvious lower than that of the upper
limbs. Further chest CT examination revealed that his descending aorta
was severely stenosis with calcification, which may be account for his
high blood pressure in upper limbs. After careful evaluation of the
patient’s condition, we finally adopted interventional therapy and
achieved good results. After operation, the patient’s upper limbs blood
pressure returned to normal, and the blood pressure gradient difference
between the upper and lower limbs disappeared.
Key words aorta; coarctation; hypertension;
Introduction
This patient was admitted to our hospital due to a complain of headache
with 1 week. One week ago, the patient had a headache without any
obvious causes, with no fever, no nausea and vomiting, and no syncope.
After admission, the blood pressure of his extremities was checked as
follows: left upper limb,180/110 mmHg; right upper limb, 185/106 mmHg;
left lower limb, 100/65 mmHg; and right lower limb,105/70 mmHg. Heart
rate, 75 beats/min; body temperature, 36.6 ℃; respiratory rate, 15
breaths/min; arterial oxygen saturation on room air, 99%. The height is
173cm, the weight is 78kg, and the body mass index is
26.1kg/m2. The patient’s laboratory test results are
as follows: total cholesterol is 6.5mmol/L, triglyceride is 3.2mmol/L,
and uric acid is 526umol/L. He had a history of hypertension for more
than 30 years, and his blood pressure was poorly controlled with
medication. He denied having a family history of hypertension, and
denied a personal history of drug abuse and promiscuity. Thise were no
obvious abnormalities in cervical vascular ultrasound. Echocardiogram
showed mild to moderate regurgitation of his aortic valve, with a
regurgitation area of 4.5cm2. Chest CT showed (Figure
1) that the descending aorta was stenosis with calcification. On the
basis of these findings, a clinical diagnosis of coarctation of the
aorta (CoA) was made.
Disscussion
Clinical Discussion
The patients had been diagnosed with hypertension for more than 30
years, but no further examination was conducted to explore the causes of
hypertension. The patient usually takes metoprolol, nifedipine, and
captopril tablets to lower his blood pressure, and the blood pressure is
controlled at 145-180/70-110mmHg. His poor blood pressure control did
not attract enough attention from hisself and clinicians. This patient
came to our hospital because of clinical symptom of headache, and he
took the initiative to request hospitalization. Since the resident
checked his blood pressure of the extremities and found the pressure
gradient difference between the upper and lower extremities, a further
chest CT examination was maded and found his aorta was stenosis. He
eventually received interventional treatment, and his blood pressure
returned to normal postoperative.
CoA is a congenital narrow of the aortic lumen1. The
typical CoA is located at the distal end of left subclavian artery and
can be before or after the ductus arteriosus. A few cases can also occur
between the left common carotid artery and the left subclavian artery.
According to the location and scope of the coarctation, aortic
coarctation is divided into pre-ductus arteriosus type (infant type) and
post-ductus arteriosus type (adult type). The clinical incidence of
infant type is about 10%, but since congestive heart failure occurs
earlier, early surgical treatment is required. If surgery is not
performed in time, most children will die in infancy. Adult type is
located at the distal of the arterial duct ligament and is mostly
limited stenosis. This type is more common, accounting for about 90%
clinically, and patients often have no symptoms. Only a few complained
of headache, cold legs, and intermittent claudication. On physical
examination, high blood pressure in the upper limbs will be found, and
systolic murmurs can be heard beside the sternum. If patients of this
type do not undergo surgery, they often die from congestive heart
failure, bacterial endocarditis, spontaneous aortic rupture and
intracranial hemorrhage.
Currently, treatments for CoA include interventional management and open
surgery2. Interventional management has become the
first choice for treatment of CoA3. It is mainly
through the implantation of a coverd stent in the aortic cavity, which
helps reduce the elastic retraction of blood vessels, thereby reducing
the incidence of postoperative restenosis. The covered stent can also
increase the strength of the blood vessel wall and help reduce the
formation of aneurysms. After careful analysis of this patient’s aortic
coarctation, we first implanted a long covered stent to cover the whole
lesion, and then implanted a covered cheatham-platinum (CP) stent.
Fortunately, the operation was successfu. The pressure gadient
difference of the two ends of stenosis was disappeared, and the effect
was satisfactory.
Imaging Discussion
Echocardiography can determine the location, length and degree of the
stenosis, and can determine whether there is an intracardiac deformity.
Other non-invasive examinations, such as CT, MRI, can clarify the
location, scope, and collateral circulation of the lesion. The
advantages of aortic CTA include the following4. 1)
show the location and extent of aortic coarctation and the length of
coarctation; 2) determine whether it is combined with intracardiac
malformations; 3) show the formation of collateral circulation; 4)
determine whether there is any change in rib bones.
The patient’s CTA examination showed (Figure 1): the descending aorta
was severely stenosis with calcification, the lesion was located 3-cm
away from the left subclavian artery, there were two constriction rings,
the scope of the lesion was limited, and no obvious collateral
circulation was seen. Preoperative angiography (Figure 2) confirmed that
this case was an adult type of aortic coarctation. The pressure gradient
difference between the two ends of the constriction was more than
80mmHg, and the minimum diameter of the stenosis was less than 70% of
the normal diameter. Postoperative angiography (Figure 3) showed that
the stenosis of the constricted section was significantly reduced, there
was no pressure difference at both ends of the constricted section, the
covered stent is properly positioned and the expanded diameter is
satisfactory.
Pathologic discussion
CoA is mostly located at the distal end of the origin of the left
subclavian artery in the aortic arch, and it is often a limited
lesion5. The pathological change of aortic coarctation
is that the posterior wall of the aorta protrudes into the ridge-like
protrusion in the aortic lumen, causing the local aortic lumen to form
an eccentric stenosis, which is sunken relative to the outer wall of the
aortic ridge-like protrusion.
The hemodynamic changes caused by the obstruction of blood flow at the
aortic constriction isthmus have the following three
conditions5. 1. The proximal end of the aortic
constriction is hypertension. The blood pressure of the upper limbs is
much higher than that of the lower limbs. Hypertension causes the left
ventricular load to increase, and leads to arteriosclerosis and cerebral
hemorrhage. 2. Insufficient blood supply to the distal aorta of the
constriction and low blood pressure can caused to renal ischemic failure
and acidosis. 3. The establishment of collateral circulation, the
internal thoracic arteries, scapular arterioles, vertebral arteries and
intercostal arteries become thicker and larger. In this case, the
arterial calcification in the constricted aorta is obvious, but the
collateral circulation is not abundant. During the operation,
intravenous infusion of antihypertensive drugs should be used to prevent
abnormal hypertension.
Conclusions
Adult patients with CoA often have no symptoms. They usually come to the
hospital for theatment due to high blood pressure in the upper limbs,
lack of pulse or weak pulsation in the lower limbs during physical
examination. This patient went to our hospital to check the blood
pressure of the extremities due to clinical symptoms and found that
there was a pressure difference between the upper and lower extremities.
A further chest CT was performed to confirm the aortic coarctation. In
clinical work, careful physical examination by clinicians is very
important, which can reduce missed or misdiagnosed and even save
patients’ lives.
Conflict of interest All authors declare that there is no
conflict of interest.
Informed consent statemen t: Informed consent and ethical
approval were waived for this report, which contains no patient
identifiable data.
Data availabity statement : All datas used during this study can
be shared.