Coarctation of the aorta complicated with bilateral iliac artery dissection: A rare case

Abstract

The coarctation of the aorta (CoA) combined with heart defects or cerebral artery aneurysms is more prevalent in clinical practice. However, cases of concurrent bilateral iliac artery dissection (IAD) are extremely rare and have not been reported. Here, we described a case with CoA combined with bilateral IAD. The patient, a 62‐year‐old male, presented with acute intermittent claudication accompanied by pain and aching in both lower limbs after walking. Following a thorough medical history inquiry and examination, the patient was diagnosed with acute bilateral IAD combined with CoA. The patient underwent endovascular treatment. Postoperatively, the aortic diameter recovered, and the bilateral IAD disappeared, yielding satisfactory therapeutic results. Conclusively, endovascular treatment of aortic coarctation combined with IAD is an effective therapeutic approach, enhancing patient survival and improving their quality of life.

1. INTRODUCTION

Coarctation of the aorta (CoA) is a rare congenital heart defect characterized by aortic coarctation. ¹ Delayed CoA diagnosis due to subtle symptoms necessitates early detection and treatment to reduce long‐term health risks. ² The main treatment methods for CoA include interventional treatment and open surgery. Isolated iliac artery dissection (IAD) is a rare condition where dissection occurs only in the iliac artery, without involving the aorta. ³ The etiology of IAD is unclear, with ongoing debates on treatment strategies. Furthermore, there is no conclusive evidence linking CoA and IAD. This report presents a case with a combination of CoA and IAD. We present the following case following the CARE reporting checklist.

2. CASE REPORT

A 62‐year‐old male patient presented with acute intermittent claudication in the left lower limb 12 days ago. The claudication was accompanied by pain and aching, with no additional discomfort. Pulse below the femoral arteries was absent in the lower limbs. A preliminary diagnosis of arteriosclerotic occlusive disease of the lower limb was made. Computed tomography angiography (CTA) indicated acute bilateral IAD (Figure 1A). We noted extensive and unusual collateral circulations from the inferior epigastric and superior epigastric arteries above the IAD (Figure 1B). CTA examination further showed a constriction in the thoracic aorta (Figure 1C). The smallest diameter measured only 3 mm, with multiple collateral circulations between the internal mammary artery, superior epigastric artery, and inferior epigastric artery, accompanied by abnormally enlarged intercostal arteries. The patient had a history of hypertension. The blood pressure was 170/90 mmHg in the upper limbs and 85/52 mmHg in the lower limbs, showing a pulse pressure gradient of 80 mmHg between them. Additionally, the ankle‐brachial index was found to be 0.5. The routine blood tests, biochemistry, immune markers, myocardial enzyme spectrum, and cardiac function laboratory indicators were within normal ranges, ruling out conditions such as large vessel vasculitis and confirming the diagnosis of CoA. Subsequently, cardiac ultrasound examination revealed left atrial enlargement, dilation of the ascending aorta, localized thickening of the interventricular septum, mild aortic valve regurgitation, mild mitral valve regurgitation, and reduced left ventricular diastolic function. Cranial MRI showed multiple ischemic degenerative changes and lacunar infarcts, ruling out intracranial aneurysms. A diagnosis of isolated CoA was made. The patient underwent endovascular surgery, which offers minimal trauma and a lower risk of complications, following standard protocol.

FIGURE 1.

CTA of the bilateral lower limbs and thoracic aorta. (A) Dissection in the left iliac artery and the right external iliac artery. (B) Preoperative CTA reveals the presence of multiple collateral circulations, while postoperative CTA demonstrates the disappearance of collateral circulations. (C) Preoperative automatic and multi‐planar reconstruction image of the thoracic aorta.

Postoperatively, the pulsation of the bilateral femoral, popliteal, dorsalis pedis and posterior tibial arteries was normal. The patient received dual antiplatelet therapy. One‐month post‐surgery, the patient stopped the antihypertensive medication, and the blood pressure stabilized at approximately 110/70 mmHg. Subsequently, the blood pressure became unstable, spiking to 150/70 mmHg, but was stabilized with temporary antihypertensive medication. During the 3‐month follow‐up, the patient showed improved exercise tolerance without intermittent claudication symptoms. The pulse pressure gradient between the upper and lower limbs was less than 10 mmHg. The ankle‐brachial index of both lower limbs was 0.9. Blood flow in the bilateral iliac and thoracic aorta was satisfactory, with no signs of dissection, arterial aneurysm, or restenosis.

3. DISCUSSION

In adults with CoA, surgery is recommended if the pressure gradient exceeds 20 mmHg or if imaging reveals clear anatomical evidence of constriction with collateral branches or systolic hypertension (blood pressure > 95th percentile). Early surgery is the consensus in the treatment of CoA due to the increased risk of developing hypertension, aneurysms, and mortality associated with treatment delay. Surgical procedures for aortic arch reconstruction should be chosen based on the patient's age, condition, and constriction location. ⁴ A study by the Congenital Cardiovascular Interventional Study Consortium highlights the advantages of interventional surgery in reducing complications and hospital stays, making it the preferred surgical method for both children and adults. ⁵ Covered stents are the preferred choice for treating CoA, but the debate between self‐expanding and balloon‐expandable types continues due to their unique advantages and disadvantages. ⁶ , ⁷ Here, we used a balloon‐expandable covered stent. This particular stent is a growth‐friendly device that can be staged with different‐sized BIB balloons for phased dilation of localized aortic coarctation. It is specifically engineered for congenital or secondary CoA, and in this case, it was associated with no complications such as aortic wall injury.

Multiple studies support that connective tissue disorders are the predominant cause of isolated IAD. ⁸ , ⁹ However, in our case, there were no significant immune abnormalities or signs of arterial atherosclerosis as revealed by CTA. Notably, IAD can also occur due to exercise. In a hyperdynamic state, joint movement and cardiac events can impose shear stress on the arterial wall, causing turbulent blood flow, intimal tears, plaque formation, and arterial wall fibrosis. ¹⁰ However, the patient in our study did not have any of these predisposing factors. The patient had bilateral IAD, which is rare compared to unilateral cases. Although we couldn't confirm it from the patient's medical history, we suspect that unconscious activities like squatting and pulling may have damaged both iliac arteries, leading to turbulent blood flow, intimal tears, plaque formation, and arterial wall fibrosis, resulting in dissection.

Early postoperative hypertension generally occurs immediately after surgery or between 48 and 72 h postoperatively. The blood pressure gradient between the upper and lower limbs consistently reduces during the follow‐up period from implantation of the covered stent to 5 years postoperatively. ¹¹ However, long‐term postoperative hypertension in patients with CoA is a common complication associated with various factors such as residual stenosis, aortic arch morphology, arterial vascular abnormalities, autonomic nervous system dysfunction, and the renin‐angiotensin‐aldosterone system, contributing significantly to cardiovascular complications. ¹² , ¹³ Some scholars argue that the surgical approach may not affect the occurrence of postoperative hypertension in patients with CoA. ¹⁴ , ¹⁵ The patient in this case, with a history of hypertension for over 20 years, was on Valsartan and Amlodipine maintaining blood pressure at 150/80 mmHg pre‐surgery. Post‐surgery, blood pressure stabilized around 110/70 mmHg without medication, with occasional spikes to 150/70 mmHg managed by temporary antihypertensives. Due to the postoperative instability of blood pressure, patients with CoA should have long‐term monitoring of blood pressure, including resting blood pressure, limb gradients, and 24‐h monitoring. Moreover, enhanced blood pressure management and annual follow‐ups with echocardiography or catheterization are recommended for assessing aortic and ventricular conditions.

In summary, the CoA combined with bilateral IAD is relatively uncommon, and its etiology remains unclear. Further research is necessary to gain a better understanding of this condition.

AUTHOR CONTRIBUTIONS

Conceptualization: Wenye He and Qingzhi Hao. Data curation: Wenye He, Qingzhi Hao, Hongsong Qin, Dawei Zhang, Yuhan Zhang, and Luyao Wang. Formal analysis: Wenye He, Qingzhi Hao, and Dawei Zhang. Funding acquisition: Qingzhi Hao and Dawei Zhang. Investigation: Wenye He, Qingzhi Hao, Hongsong Qin, Dawei Zhang, Yuhan Zhang, and Luyao Wang. Writing—original draft: Wenye He. Writing—review & editing: Wenye He and Qingzhi Hao.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

PATIENT CONSENT STATEMENT

Informed consent for publication of photographs and information was obtained from this patient.

PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES

Not applicable.

CLINICAL TRIAL REGISTRATION

There were no clinical trials in this case report.

He W, Zhang Y, Wang L, Qin H, Zhang D, Hao Q. Coarctation of the aorta complicated with bilateral iliac artery dissection: A rare case. J Clin Hypertens. 2024;26:986–989. 10.1111/jch.14847

DATA AVAILABILITY STATEMENT

Data sharing does not apply to this article as no new data were created or analyzed in this study.