surgical treatment includes resection of the narrow segment with end - to - end anastomosis of the aorta and aortoplasty using a subclavian flap or synthetic material . these techniques show initially excellent results ; however , late anastomotic pseudoaneurysms develop in 3 to 38% of all cases [ 1 , 2 ] . reoperation in these patients is complex and associated with high morbidity and mortality [ 25 ] . therefore , in the last decade endovascular techniques emerged to treat these complications [ 59 ] , based on the experience of endovascular treatment in atherosclerotic aneurysms in this location . we report the case of two patients with pseudoaneurysms after previous surgical repair which were treated by endovascular means . a 31-year - old female patient underwent surgical correction of aortic coarctation at the age of 4 years using a goretex patch . during a routine angio - ct 17 years after the initial surgery , a recoarctation and a pseudoaneurysm were diagnosed , and a balloon - expandable stent was placed at the recoarctation site . a control angio - ct showed stent migration and growth of the pseudoaneurysm measuring 53  40  mm in diameter . in contrast to the previous angio - ct , the pseudoaneurysm was multilobulated with irregular walls , and the origin of the left subclavian artery was dilated with 25  mm in diameter . due to the morphologic changes and the size of the pseudoaneurysm , this patient was referred to our institution for endovascular treatment . before treatment the angiography showed a small caliber aortic arch with severe angulation and a pseudoaneurysm , that extended proximally to the origin of the left subclavian artery . the balloon - expandable stent was in contact with the aortic wall only at its distal end ( figure 1(a ) ) . treatment was performed in two times . under general anesthesia a left carotid - subclavian bypass was performed using prosthetic goretex of 8  mm , and the left subclavian artery was ligated . two days after the surgery , the endovascular treatment was performed under general anesthesia and systemic heparinization . a right femoral access was used to introduce a captivia ( medtronic vascular , santa rosa , ca ) thoracic endoprosthesis , 22  150  mm . the device was released covering the origin of the left subclavian artery ( figure 1(b ) ) . no complication was found in the angio - ct ( figures 1(c ) and 1(d ) ) . after 3 months the patient was asymptomatic without evidence of pathologic images in the control angio - ct . a 46-years - old male patient , who presented with mild hemoptysis at our institution , was operated at the age of 17 years for aortic coarctation using a prosthetic patch . in the angio - ct a pseudoaneurysm was diagnosed as a late complication of surgery of aortic coarctation measuring 64  68  mm in diameter . the diagnostic angiogram showed a saccular and irregular shaped pseudoaneurysm ( figure 2(a ) ) . the right vertebral artery was found to be patent without atherosclerotic lesions and of preserved diameter . an aortobronchial fistula could be identified neither in the angio - ct nor in the diagnostic angiogram . under general anesthesia and systemic heparinization the right common femoral artery was dissected , and a first endoprosthesis body zenith tx2 ( cook inc , bloomington , in ) 22  115  mm was introduced and released , covering the left subclavian artery . after that , a second endoprosthesis body captivia ( medtronic vascular , santa rosa , ca ) 26 - 26 - 150  mm was used to exclude the pseudoaneurysm . due to the risk of death caused by severe hemoptysis , an emergency treatment was considered , consisting in endovascular bridging with stent grafts and proximal occlusion of the left subclavian artery . for this reason , two different endoprosthesis were used , since no other stent grafts , available in our stock , met the required characteristics . after liberating both devices a latex balloon the final angiogram showed no leaks with present collateral flow in the left subclavian artery ( figures 2(b ) and 2(c ) ) via right vertebral artery . there was an uncertainty , whether there was a leak type i or ii , additionally a pseudoaneurysm in the right subclavian artery was found which was considered iatrogenic after placement of a jugular central line .   through a right brachial access the pseudoaneurysm was embolized with 3 microcoils ( trufill , cordis , miami lakes , fl . ) ( figures 3(b ) and 3(c ) ) . the same access was used to clearly demonstrate a leak type i of the first endoprosthesis body ( figure 3(d ) ) . under general anesthesia a 23-mm angioplasty balloon catheter was delivered through a left femoral artery access to successfully seal the leak .   before discharging the patient , a control angio - ct was performed , and no leak could be identified . at the 6-month follow - up the patient remained asymptomatic without hemoptysis and without other evidence of leakage or pathologic images in the angio - ct . among the surgical techniques for the treatment of aortic coarctation , the surgical resection and end - to - end anastomosis has demonstrated low complication rates ; however , late complications are still common [ 1 , 2 ] . late pseudoaneurysms should not be left untreated , as rupture has been described even in small pseudoaneurysms . reoperation in these patients is complex and is associated with high mortality and morbidity such as paraplegia , recurrent nerve paralysis , and bleeding . in the last decade , endovascular techniques were introduced for the treatment of late complications after coarctation surgery in order to reduce complications related to open surgery . even if the reported series are small , they show very encouraging results [ 59 ] . the technical difficulty of treating these patients includes hypoplastic aortic arch , proximal fixation zone in relation to the extension of the pseudoaneurysm and the dimension of the access arteries . none of our patients had aortic arch hyperplasia ; however one case presented with a severe angulated arch and a small diameter aorta . additionally , the procedure was complicated by an aortic stent which was attached to the arterial wall only by the distal end . in this kind of patient and in patients with small caliber accessing arteries , friction and resistance can complicate the procedure , not permitting the device to be delivered to the proximal anchoring zone . the use of new devices with hydrophilic coating could help to overcome problems with angled arches , intravascular devices , and small accessing arteries .   in both cases the left subclavian artery had to be covered . in the first case , the left subclavian artery was revascularized through a carotid - subclavian bypass , and in the second case the subclavian artery was embolized using an amplatzer device . left subclavian artery occlusion is generally well tolerated ; however there are several studies reporting the risk of complications such as superior extremity claudication or associated neurological symptoms [ 1013 ] . preinterventional angiography of the supraaortic vessels should be performed in order to demonstrate collateralization blood flow from the right to the left vertebral artery . these studies have been conducted on a patient population with atherosclerotic disease in which the collateral pathway , like vertebral arteries or the thyrocervical trunk , may be affected by the arteriosclerotic angiopathy . however , young patients usually do not have atherosclerotic disease , therefore occlusion of the left subclavian artery might be better tolerated . in a previous publication we reported the case of a young patient with traumatic aortic rupture in whom the left vertebral artery originated directly from the aortic arch . in this case , despite independent embolization of left vertebral artery and left subclavian artery due to a type ii leak , no neurological symptoms or signs of claudication in the left upper limb could be found , and the ipsilateral brachial and radial pulse was palpable in the following controls . although there are reports of endovascular treatment in late complications after surgical repair of aortic coarctation , these reports include a small number of patients . the published results are very encouraging , and with new devices more patients with complex anatomy can be treated safely with a high technical success . the endovascular treatment is an important alternative to surgical reoperation due to its lower morbidity and mortality . however , more data from long - term monitoring are needed to determine their effectiveness and to detect late complications .
late complications after surgical repair of aortic coarctation are not uncommon . among these complications 
 pseudoaneurysms are the most frequent complications , occurring between 3 and 38% . 
 reoperation in these patients is associated with high morbidity and mortality . in the last decade , 
 endovascular techniques emerged as an alternative to conventional surgery with excellent results . 
 we report the case of two patients who presented with pseudoaneurysms after surgical correction for aortic coarctation , which were treated by endovascular means .