Case Description. This patient is a 54-year-old woman with a history of coarctation of the aorta who underwent surgical repair 34 years ago, with placement of a Dacron graft (1 cm in diameter) from the ascending to descending aorta. Anatomically, she also has a right-sided aortic arch and anomalous origins of the great vessels (Figure 1). The first great vessel is the right carotid artery arising from the distal ascending aorta. The second great vessel is the right subclavian artery. The innominate originates from the descending aorta and supplies the left subclavian and carotid arteries. The aortic arch is diffusely hypoplastic after the origin of the right carotid artery, and stenotic at the level of the right subclavian artery. The aortic graft arises in the mid-segment of the ascending aorta and courses posteriorly to the descending aorta attaching above the origin of the left innonimate artery. She presented to the emergency room with increasing dyspnea, exertional back pain and right arm numbness and discomfort. Physical examination at the time of admission revealed blood pressures in the right and left upper extremeties of 150/80 mmHg and 120/70 mmHg, respectively. The lungs were clear and cardiac examination was without an S3, but did have an S4. Myocardial infarction was ruled out by cardiac enzymes. Angiography confirmed the right-sided arch and the great vessel anatomy as described. Descending aortic pressure, measured at the level of the abdominal aorta, was 120/70 mmHg (mean 90 mmHg) compared with an ascending aortic, (measured proximal to the graft), and LV pressures of 240/110 mmHg (mean 155 mmHg) and 240/17 mmHg, respectively. The mean gradient (measured via a 4 French multipurpose catheter) across the coarctation was 55 mmHg at baseline. Angiography of the aortic graft revealed a high-grade stenosis with moderate calcification at its origin, with tubular lesions in the mid segment and in the distal anastamosis to the descending aorta. Pressure gradients across the graft were measured via a 0.014´´ RADI pressure wire positioned in the descending aorta through the graft and a catheter in the Sinus of Valsalva. The mean gradient across the graft was 40 mmHg with a peak gradient of 80 mmHg (Figure 2). Patient management. The patient underwent MRA and CT of the chest to fully delineate the coarctation and its relation to the great vessels. Given the hypoplastic nature of the arch and its proximity to the takeoff of the right subclavian artery, the plan was to dilate and stent the aortic graft. If a significant gradient from the ascending to descending aorta remained, then percutaneous repair of the coarctation would follow. The patient returned to the catheterization laboratory where a 10 French hockey stick guiding catheter was placed into the ostium of the aortic graft. A choice PT extra support wire crossed the lesions without difficulty. IVUS confirmed the maximal lumen diameter of the graft was 10 mm, with a minimum lumen diameter of 2.5 mm at the ostium. The mid and distal segments also had moderate to severe diffuse disease. Through a 6 mm peripheral balloon the wire was exchanged for a 0.035´´ Amplatz Super Stiff wire. Over this wire, a 6 mm x 20 mm balloon was used to predilate the ostial segment to confirm adequate expansion. Following this initial inflation, the ostium was stented with a Palmaz P204 (20 mm non-articulated) stent crimped on a 10 mm x 20 Power Flex balloon inflated to 18 atms. The residual stenosis was 0% with excellent flow. Two overlapping Palmaz P154 (15 mm) stents were deployed with the 10 mm balloon inflated to 20 atms to the mid segment of the graft. The residual stenosis was 0% with excellent flow. Finally a Palmaz P154 (15 mm) stent was deployed in the distal portion of the graft in its outflow to the descending aorta. The final angiography revealed 0% residual stenosis (Figure 3) within the graft and the mean gradient had declined to 9 mmHg from the baseline gradient of 40 mmHg. The systolic pressure difference decreased to
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