Multimodality Imaging of Acute Stanford Type B Dissection during Balloon Angioplasty for Native Aortic Coarctation

Graphical abstract

Highlights

• •TTE identified severe CoA with classic Doppler findings and high systolic gradient.
• •CTA defined CoA anatomy, landing zones, and access site.
• •Angiography promptly detected acute Stanford type B dissection.
• •Thoracic stent graft achieved complete sealing of the dissection entry tear.
• •Imaging follow-up showed laminar flow and full false-lumen thrombosis.

Introduction

Native coarctation of the aorta (CoA) is a congenital cardiovascular abnormality that may remain undiagnosed until adulthood and often presents with long-standing hypertension, left ventricular hypertrophy (LVH), and symptoms of reduced distal perfusion.¹ Transthoracic echocardiography (TTE) frequently provides the first diagnostic clue by allowing noninvasive assessment of hemodynamic severity and ventricular remodeling.² Complementary tomographic imaging with computed tomography angiography (CTA) enables precise anatomic characterization and procedural planning.³ Multimodality imaging is therefore fundamental for early diagnosis, complication detection, and procedural guidance.⁴

Herein, we present a case in which TTE and CTA established the diagnosis of severe native CoA in a young woman with resistant hypertension and a history of hypertensive pregnancy loss. During preparatory balloon dilatation, the patient developed an acute Stanford type B aortic dissection, as identified by angiography, and was successfully managed with thoracic endovascular aortic repair (TEVAR). This case highlights the pivotal role of multimodality imaging in the recognition of complications and emphasizes the importance of evaluating secondary causes of hypertension in young adults.

Case Presentation

A 22-year-old woman presented with progressive exertional dyspnea, which had progressed over 1 year from New York Heart Association functional class I to III. The patient experienced exertional angina, frontal headache, presyncope, and bilateral lower limb claudication; denied orthopnea, pedal edema, cough, or fever; but reported long-standing resistant hypertension despite treatment with 3 antihypertensive agents, including a diuretic. The patient's medical history included grade II hypertensive retinopathy and spontaneous abortion at 20 weeks of gestation due to severe hypertensive complications. No family history of cardiovascular disease was recorded.

On examination, the blood pressure was 186/96 mm Hg in the right arm and 182/98 mm Hg in the left arm, compared with 116/68 mm Hg (right) and 108/66 mm Hg (left) in the lower limbs. Radial-femoral delay was also observed. An ejection systolic murmur was detected in the left infraclavicular region. No other systemic abnormalities were observed. The differential diagnoses included native CoA, Takayasu arteritis, and supravalvular aortic stenosis.

Chest radiography revealed pre- and poststenotic dilatation of the descending thoracic aorta (Figure 1A). Electrocardiography revealed sinus rhythm with LVH (Figure 1B). Fundoscopy confirmed bilateral grade II hypertensive retinopathy (Figure 1C, 1D).

Figure 1.

Chest radiograph, posterior-anterior projection (A), 12-lead electrocardiogram (B), and fundoscopic images (C, D), demonstrate pre- and poststenotic dilatation of the descending thoracic aorta (yellow line), sinus rhythm with LVH, bilateral, grade II hypertensive retinopathy.

Transthoracic echocardiography revealed severe juxtaductal coarctation with a peak systolic gradient of 109 mm Hg, concentric LVH, normal visually estimated left ventricular systolic function, and a tardus-parvus waveform in the abdominal aorta (Figure 2A-2D, Video 1). The aortic valve was structurally normal and trileaflet, with no evidence of stenosis or regurgitation (Video 2). These findings confirmed significant hemodynamic obstruction and warranted tomographic imaging.

Figure 2.

Two-dimensional (2D) TTE, suprasternal long-axis systolic view with color-flow Doppler (A) and continuous-wave spectral Doppler display (B), demonstrates turbulent flow across the juxtaductal coarctation segment with a continuous antegrade profile including a high-velocity diastolic tail and a peak systolic gradient of 109 mm Hg; 2D-aligned M mode from the parasternal long-axis view (C) demonstrates increased myocardial wall thickness; subcostal, long-axis abdominal aortic view, continuous-wave spectral Doppler display (D), demonstrates a tardus-parvus waveform.

Computed tomography angiography revealed a discrete juxtaductal coarctation, measuring 5.1 mm, distal to the origin of the left subclavian artery, accompanied by pre- and poststenotic dilatation (Figure 3A). Adequate proximal and distal landing zones, along with suitable iliofemoral access dimensions, were confirmed (Figure 3B-3D), supporting the endovascular stent-based repair.

Figure 3.

Computed tomography angiogram, three-dimensional volume-rendered reconstructions of the sagittal thoracic aorta (A-C) and coronal iliac and femoral arteries (D), demonstrates the juxtaductal coarctation in the descending thoracic aorta distal to the left subclavian artery with multiple serial, cross-sectional axial measurements (B, D) confirming a minimum diameter of 5.1 mm and reporting preprocedural landing zone measurements (proximal, 15 mm; coarctation length, 24 mm; distal, 20 mm; right common iliac, 6.3 mm; left common iliac, 6.2 mm; right femoral, 6.2 mm; left femoral, 6.4 mm).

The patient underwent balloon angioplasty via right femoral artery access. Aortography delineated the coarctation anatomy and confirmed the severity of luminal narrowing (Figure 4A, Video 3). Before the planned stent implantation, preparatory balloon angioplasty was performed to assess lesion compliance (Figure 4B). During balloon inflation, the patient developed acute chest and back pain. Immediate repeat aortography revealed an acute Stanford type B aortic dissection extending from the coarctation site into the descending thoracic aorta (Figure 4C, Video 4), without any angiographic evidence of ascending aortic involvement. Intraoperative imaging did not reveal pericardial effusion. The localization of the dissection and absence of Stanford type A features guided the decision for immediate endovascular management in a hybrid operating suite. Conversely, extension into the ascending aorta or evidence of pericardial compromise would necessitate urgent open surgical repair.

Figure 4.

Periprocedural, digital subtraction angiographic projections, oblique anteroposterior displays, demonstrates the coarctation segment (A, single arrow), the balloon (10 × 40 mm) dilatation (B, single arrow), contrast injection with an acute Stanford type B thoracic aortic dissection (multiple arrows) originating at the coarctation and extending into the descending aorta (C) and following deployment of a thoracic stent graft (20 × 20 × 82 mm) with restoration of true lumen flow (D).

Because the dissection extended beyond the coarctation segment and required long-segment coverage, a thoracic endovascular stent graft was selected based on the availability of an appropriate diameter and length for adequate coverage and deployed via surgical right femoral cutdown under general anesthesia, achieving complete sealing of the entry tear (Figure 4D, Video 5). Postdeployment angiography confirmed exclusion of the false lumen and restoration of luminal caliber.

The patient was extubated within 6 hours and remained hemodynamically stable. The peak-to-peak pressure gradient was 40 mm Hg following stent deployment. At the 1-month follow-up, she was normotensive and asymptomatic while receiving a single antihypertensive agent. Transthoracic echocardiography demonstrated laminar flow across the stented segment (Figure 5A, Video 6), with a peak systolic gradient of 43 mm Hg (Figure 5B). Computed tomography angiography confirmed the appropriate stent position with complete false-lumen thrombosis (Figure 5C).

Figure 5.

Transthoracic echocardiography and CTA imaging at 1-month follow-up after thoracic endovascular repair. Two-dimensional TTE, suprasternal long-axis systolic view with color-flow Doppler (A) and continuous-wave spectral Doppler display (B), demonstrates laminar antegrade flow across the stented coarctation segment with continuous antegrade profile including a low-velocity diastolic tail and a peak systolic gradient of 43 mm Hg; CTA, three-dimensional volume-rendered reconstruction of the sagittal thoracic aorta (C), demonstrates appropriate thoracic stent graft position with complete false-lumen thrombosis and no evidence of endoleak.

Discussion

In the present case, acute Stanford type B aortic dissection occurred during balloon angioplasty for native CoA in a young woman with severe, treatment-resistant hypertension. Initial multimodality imaging demonstrated severe juxtaductal narrowing with reduced aortic distensibility, a feature that is known to increase procedural vulnerability due to chronic hypertension and decreased aortic compliance. These factors, combined with poststenotic dilatation, likely increase susceptibility to mechanical aortic wall injury.^5,6 Although dissection during balloon inflation is uncommon, it is a recognized complication of aortic interventions, particularly in adults with long-standing hemodynamic obstruction.

Coarctation of the aorta complicated by Stanford type B dissection is an exceptionally rare clinical condition. A recent systematic review identified only 22 reported cases worldwide, underscoring the infrequency of this association and the absence of standardized management strategies.⁷ Most published cases describe spontaneous or chronic dissections occurring in untreated CoA rather than intraprocedural iatrogenic injuries.

Current international guidelines recommend stent-based repair as the first-line therapy for adult native CoA, with balloon dilatation serving as an adjunctive step to assess lesion compliance and facilitate optimal stent expansion.⁸ In this case, preparatory balloon dilatation was performed, consistent with contemporary practice. However, this complication highlights the inherent procedural risks associated with rigid, hypertensive aortas.

Historically, open surgical repair has been the dominant therapeutic approach for adults with CoA complicated by poststenotic aneurysm or dissection. A contemporary surgical series by Qiao et al.⁹ reported high technical success and favorable short- to midterm outcomes using individualized open repair strategies, emphasizing surgical feasibility in anatomically complex diseases. Earlier reports similarly favored open correction in chronic Stanford type B dissections associated with CoA.¹⁰ These surgical data provide an important benchmark for comparison.

Endovascular repair is recommended for complex acute Stanford type B dissections, including iatrogenic injuries, as supported by the 2024 European Society of Cardiology Guidelines on Aortic Disease.11, 12, 13 In our patient, the dissection extended beyond the coarctation segment, requiring a device capable of sealing the entry tear and providing adequate coverage of the dissected thoracic aorta. Although balloon-expandable covered stents are commonly used in adult CoA interventions, their short length and limited conformability render them suboptimal for long-segment dissections. Therefore, TEVAR was selected to achieve complete and durable exclusion of the false lumen and to prevent reoperation. Emerging case-level evidence supports the feasibility of endovascular therapy for complex CoA-related dissecting pathology. Jata et al.¹⁴ described successful thoracic stent-graft treatment of a coarctation-associated dissecting aneurysm, demonstrating durable imaging results at a 3-year follow-up. Furthermore, a recent case series demonstrated effective transcatheter endovascular management of complex native CoA guided by advanced tomographic imaging.¹⁵ Collectively, these findings support an expanding role for endovascular strategies in anatomically suitable patients. The patient's favorable short-term outcomes, including improved blood pressure control, complete false-lumen thrombosis, and stable graft position, align with the published data on TEVAR for acute descending thoracic aortic pathologies.

Beyond acute complications, this case highlights the importance of evaluating secondary causes of hypertension in young adults, particularly in women of reproductive age. Early diagnosis and intervention may prevent hypertensive end-organ damage and adverse pregnancy outcomes.

This report has some limitations. First, it reports a single-center experience with individualized decision-making based on anatomical findings and available resources. Second, the use of a thoracic stent graft represents an off-label application in this context and may not be feasible in all settings. Moreover, long-term imaging follow-up beyond the early postprocedural period is currently unavailable; therefore, the durability of the repair and the risk of recoarctation or graft-related complications require continuous surveillance. Delayed diagnosis of CoA may also have influenced the patient's clinical presentation, including previous hypertensive pregnancy complications.

Conclusion

This case demonstrates the critical role of multimodal cardiovascular imaging, particularly echocardiography and CTA, in diagnosing native CoA and guiding endovascular management. Prompt recognition of acute Stanford type B dissection using intraprocedural imaging enabled rapid imaging-directed intervention, resulting in favorable short-term outcomes. TEVAR represents an effective therapeutic option in selected cases of acute aortic wall injury complicating coarctation interventions. In summary, this case suggests early imaging assessment remains essential in young adults with resistant or unexplained hypertension.

Consent Statement

The authors declare that informed written consent was obtained from the patient for the publication of this case report and accompanying images, in accordance with the COPE guidelines.

Ethics Statement

The authors declare that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans

Funding

The authors declare that this report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure Statement

The authors reported no actual or potential conflicts of interest relative to this document.

Supplementary data

The following is/are the supplementary data to this article.

Video 1

Two-dimensional TTE, suprasternal long-axis view with color-flow Doppler, demonstrates turbulent flow across the juxtaductal coarctation segment.

Video 2

Two-dimensional TTE, parasternal short-axis view at the level of the aortic valve, demonstrates a structurally normal trileaflet aortic valve without stenosis.

Video 3

Digital subtraction angiography, oblique anteroposterior projection, demonstrates a discrete juxtaductal coarctation and preprocedural aortic anatomy.

Video 4

Digital subtraction angiography, oblique anteroposterior projection, demonstrates an acute Stanford type B aortic dissection with contrast outlining the extension from the coarctation site into the descending thoracic aorta.

Video 5

Digital subtraction angiography, oblique anteroposterior projection, demonstrates the deployed thoracic stent-graft (20 × 20 × 82 mm) with restoration of true lumen flow.

Video 6

Two-dimensional TTE, suprasternal long-axis view with color-flow Doppler obtained at 1-month follow-up after thoracic endovascular repair, demonstrates laminar antegrade flow across the stented coarctation segment.