Aortic Isthmus Pseudoaneurysm After Coarctation Repair as a Source of Thromboembolism

A 60 year old male, smoker with a past medical history of moderate hypertension, hypercholesterolemia, bronchial asthma and surgically corrected aortic coarctation with interposition grafting at the age of 17, was presented with four episodes of post-exercise lower limb thromboembolism within a period of two years. The electrocardiogram was normal and multiple Holter recordings showed no rhythm abnormalities. The cardiac transthoracic echocardiogram showed normal left ventricular dimensions and systolic function, normal right ventricle, bicuspid aortic valve with moderate insufficiency and mild stenosis, ascending aorta with a diameter of 46mm, and a pressure gradient across the aortic isthmus of 20mmHg. The cardiac transesophageal echocardiogram revealed no intracardiac thrombi or shunts and in addition neither dissection nor thrombus in the descending thoracic aorta was detected. Although the patient was subjected to multiple diagnostic imaging examinations, it was the Dual Source Computed Tomography with three-dimensional image reconstruction of the aorta that disclosed the detachment of the graft's wall inner surface at the site of its proximal anastomosis with the descending thoracic aorta, just distal to the origin of the left subclavian artery, that resulted in the formation of a pseudoaneurysm which served as the source of distally embolizing thrombi. Moreover, in the distal thoracic aorta just after the graft's distal anastomosis, a mild stenosis occurred due to intense intramural calcification. Although various therapeutic approaches were considered, the patient was finally taken to the operating theatre, where, via a left lateral thoracotomy, the preoperative findings were confirmed and the lesions successfully repaired.