Novel Approach in Treatment of Coarctation of the Aorta with Bifurcation Stenosis of the Left Subclavian Artery - The Road Less Traveled

Abstract

Endovascular stenting has emerged as the preferred treatment modality for coarctation of the aorta (CoA). However, CoA can sometimes extend beyond the aortic arch, involving adjacent vessels such as the left subclavian artery (LSA), which complicates conventional interventions. We present a case of CoA associated with proximal LSA stenosis which was successfully treated using a double-wire stent technique. The technique does not compromise the LSA flow and offers a promising alternative in complex CoA cases. A 19-year-old female presented with palpitations with dyspnea (New York Heart Association grade III) for 15 days. She also gave a history of intermittent claudication in the left upper limb for 3 years. Clinical examination revealed pallor and weak pulses in the left upper extremity and both lower extremities, with radio-radial and radio-femoral delays. Blood pressure measurements indicated significant gradients between the limbs, with readings of 244/112 mmHg in the right upper limb, 162/104 mmHg in the left upper limb, and 114/74 mmHg and 116/78 mmHg in the right and left lower limbs, respectively. Auscultation revealed normal S1 and S2 and a systolic murmur in the right interscapular area. Electrocardiogram revealed sinus arrhythmia with T-wave inversions in leads II, aVF, and V1-V6. Echocardiogram revealed severe postductal coarctation with a gradient of 84 mmHg. Computed tomography aortography confirmed a severe coarctation-preductal diameter of 12 mm and postductal diameter of 14 mm, with a concomitant LSA stenosis of 7 mm. The critical challenge in this case was stenting the coarctation without compromising the already symptomatic LSA stenosis. A novel endovascular approach was employed, utilizing two preplaced wires in both the aorta and LSA, followed by deployment of an uncovered stent and final kissing balloon angioplasty. This is the first instance in literature of such an approach being taken. Patients with CoA with associated bifurcation stenosis of the LSA are extremely rare and pose significant challenges for endovascular management. This case highlights a novel and effective interventional strategy, offering a tailored approach to preserve LSA patency while addressing the complex CoA anatomy.

Keywords: Angioplasty; case report; coarctation of the aorta; endovascular interventions; left subclavian artery; stenting.

Figure 1

Electrocardiogram revealed sinus arrhythmia with T-wave inversions in leads II, aVF, and V1–V6

Figure 2

(a) Echocardiogram showing severe postductal coarctation of the aorta. (b) Doppler showing a gradient of 73 mmHg

Figure 3

Computed tomography aortogram showing coarctation of the aorta with preductal diameter of 12.96 mm, postductal diameter of 14.46 mm, and left subclavian artery stenosis of 7 mm

Figure 4

Novel approach of bifurcation stenting of the left subclavian artery using kissing balloon angioplasty in coarctation of the aorta (CoA). (a) Aortic angiogram showing CoA. (b) Pictorial representation of CoA. (c) Pre- and postductal aortic diameters. (d) Dilatation of CoA. (e) Wire crossed into the left subclavian artery. (f) CoA and left subclavian artery stenosis angiogram through pigtail catheter. (g) Stent positioning across CoA over the 14F sheath. (h) Stent deployment at 6 atm with cardiac pacing. (i) Withdrawal of balloon. (j and k) Proximal flaring with 6.0 mm × 60 mm balloon in stent to the left subclavian artery and 12 mm × 40 mm balloon in the aorta under cardiac pacing. (l) Final result

Figure 5

(a) Preprocedure hemodynamics showing a gradient of 73 mmHg. (b) Postprocedure hemodynamics showing a gradient of 5 mmHg