A 56-year-old male patient with coronary artery disease (CAD) and hypertension was referred with exertional dyspnea (NYHA II). Past medical history revealed that he had coarctation which was surgically corrected with a 16 mm x 20 mm Dacron tube graft at 21 years of age. On examination, his right upper limb blood pressure was 180/90 mmHg. The femoral pulses were faint. Radial femoral delay was apparent and blood pressure gradient of 30 mmHg was noted between upper and lower extremities. Chest X-ray revealed rib notching. Echocardiography showed a significant narrowing in the descending aorta just distal to subclavian artery inside the tube graft with peak gradient of 38 mmHg and mean gradient of 16 mmHg with diastolic spillage. There was concentric left ventricular hypertrophy with good systolic function. Contrast-enhanced computed tomography revealed severe stenosis at the proximal and distal anastomosis of the Dacron tube graft [Figures 1 and 2].
A decision was made to proceed with staged coronary angiography and later CoA stenting. Coronary angiogram revealed mid left anterior descending artery and diagonal disease which were stented. Two weeks later, the patient went for CoA stenting.
Under general anesthesia, a 7F sheath was placed in the left femoral artery and a 6F sheath in the right radial artery. The coarctation site was crossed with 0.035 cm x 150 cm Terumo guidewire and 6F multipurpose catheter. Simultaneous recording from the ascending aorta and descending aorta revealed a peak-to-peak gradient of 54 mmHg.
Ascending aorta angiogram [Figure 3] showed severe coarctation at the sites of proximal and distal anastomosis (6 mm each) of the tubed conduit and normal head and neck branches. The conduit length was 20 mm and diameter 14 mm. A 0.035 cm x 260 cm Amplatz super stiff wire was placed in the right subclavian artery for stability and a 14F Check Flo-Cook long sheath was placed over the wire. A 39-mm Cheatham platinum (CP)-covered stent (NuMed Inc., Hopkinton, New York, USA) was mounted to 14 mm x 40 mm BIB balloon to BIB catheter. Stent position was confirmed using aortic arch angiogram through the right radial artery approach. The stent was deployed inside the Dacron graft with right ventricular pacing at 170 bpm.
Poststent implantation, the gradient dropped to 11 mmHg. The covered stent was postdilated with a 16 mm x 45 mm BIB balloon twice with good flaring of the proximal and distal ends of stent. Postballoon, dilatation revealed still further drop in gradient to 8 mmHg. Final angiogram [Figure 4] confirmed the good stent position and absence of any extravasation or tear. The measurements at proximal and distal coarctation sites were 14 mm each. The patient had uneventful recovery and discharged home the next day. Currently, the patient is asymptomatic and weaning off all antihypertensive medications.