Figure of 3-sign: a case report

Abstract

Background: A 50-year-old mother of four children was newly diagnosed with arterial hypertension and bilateral neck pulsations.

Case summary: Her current blood pressure was 170/100 mmHg in the right arm and 122 mmHg systolic in the right ankle. There was a radio-femoral delay palpable. The electrocardiogram showed signs of left ventricular hypertrophy. On the chest X-ray, a figure of 3-sign was found at the aortic knuckle and notching of the inferior ribs was present. An echocardiogram showed concentric left ventricular hypertrophy, a mildly stenotic bicuspid aortic valve, and a low peak-gradient across the descending aorta. Magnetic resonance imaging demonstrated severe focal coarctation with complete interruption of the descending aorta. Large collaterals vessels were present, effectively bridging the aortic interruption.

Discussion: In light of the extensive collateral vessels and the bleeding risk, an extra-anatomic aortic bypass was considered the least risky procedure. The patient agreed to the intervention and had an uncomplicated surgical course and recovery. At the 12-month follow-up, she was doing well and normotensive on Lisinopril 5 mg OD.

Keywords: Case report; Coarctation of the aorta; Extra-anatomic aortic bypass; Hypertension.

Figure 1

(A) Resting 12-lead electrocardiogram with signs of left ventricular hypertrophy (positive Sokolow-Lyon index). (B) Chest X-ray with a figure of 3-sign produced by the dilated left subclavian artery, the narrowing at the aortic isthmus, and the post-stenotic dilatation of the descending aorta. There is also notching of the ribs (arrow). (C) Continuous wave Doppler across the region of the aortic isthmus shows a serrated flow pattern and low transcoarctation velocities of 1.3 m/s. (D) On a cardiac magnetic resonance imaging severe focal coarctation of the aorta with probable complete interruption after the aortic arch was present. Abdominal blood flow was maintained by numerous large collateral vessels.