PMC9815109_01
Transthoracic echocardiography of the aortic valve (A-E) and CoA (F,G). Parasternal long-axis view of the aortic valve open (A) and closed with a mobile mass on the non-coronary cusp (B). Parasternal short-axis view of BAV open (C) and closed (D). Apical five-chamber view of the BAV with moderate aortic regurgitation with color doppler (E). Suprasternal view of the aortic arch and CoA with color doppler (F). Sawtooth pattern on echo doppler of the CoA (G). LV, left ventricle; RV, right ventricle; LA, left atrium; AA, ascending aorta; DA, descending aorta; RVOT, right ventricular outflow tract; BAV, bicuspid aortic valve; RCC, right coronary cusp; LCC, left coronary cusp; NCC, non-coronary cusp; Arch, aortic arch; CoA, coarctation of the aorta, *Mobile mass; **raphe between the NCC and LCC.
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F1
Moreover, mild dilation of the ascending aorta (38 mm) and narrowing of the aorta distal from the origin of the left subclavian artery with the antegrade diastolic flow in the thoracic aorta with a typical "saw tooth" pattern and an estimated pressure gradient of 78 mmHg (Vmax 4.4 m/s) was observed, indicating significant aortic coarctation (Figures 1A-G).
Postero-anterior chest radiograph illustrates the aneurysmatic collateral artery projecting over the apical-medial aspect left upper lobe and mediastinal silhouette (A). In addition, the postero-anterior chest radiograph with multifocal rib notching (red arrows) and projection of the cinematic 3D-reconstruction of the thoracic aorta illustrating the CoA and associated aneurysmatic collateral artery (B). Oblique sagittally reformatted maximum intensity projection (MIP) cinematic 3D-rendering of thoracic CTA shows hypertrophic collateral arteries posterior (C) and lateral (D) alongside the chest wall, indicated by green arrows. The sagittal CTA image illustrating collateral arteries and hypertrophic intercostal arteries inserting into the descending aorta (E), and the levoartriocardinal vein (F). AA, ascending aorta; DA, descending aorta; CA, aneurysmatic collateral artery; LSA, left subclavian artery; LCA, left carotid artery; TBC, truncus brachiocephalicus; Arch, aortic arch; LSA, left subclavian artery; LA, left atrium; LACV, levoatriocardinal vein; LBCV, left brachiocephalic vein.
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F2
A chest X-ray showed subtle bilateral notching on the inferior borders of several posterior ribs and a rounded opacity projecting over the paramediastinal aspect of the left upper lobe (Figures 2A, B). Furthermore, CTA revealed hypertrophic intercostal, internal mammary, and scapular arteries (Figures 2C-E), a levoatriocardinal vein (LACV) connecting the truncus brachiocephalicus with the left atrium (Figure 2F), and an extensive intrathoracic collateral network with a large paravertebral aneurysm (29 x 24 x 24 mm) of one of the collateral arteries arising from the left subclavian artery (Figures 3A, C, E).
Computed tomography (CT) angiography of the aorta before (A,C,E) and 4 months after (B,D,F) implantation of a covered stent across the CoA. The transverse plane is at the level of the CoA (A,B) and the level of the left paravertebral aneurysmatic collateral artery (C,D). Cinematic 3D reconstruction of the thoracic aorta, illustrating the CoA and associated aneurysmatic collateral artery (E,F). AA, ascending aorta; DA, descending aorta; LACV, levoatriocardinal vein; CoA, coarctation of the aorta; Stent, covered stent in the coarctation zone; CA, aneurysmatic collateral artery; CA*, location of the aneurysmatic collateral artery; RSA, right subclavian artery; LSA, left subclavian artery; LCA, left carotid artery; TBC, truncus brachiocephalicus.
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F3
Furthermore, CTA revealed hypertrophic intercostal, internal mammary, and scapular arteries (Figures 2C-E), a levoatriocardinal vein (LACV) connecting the truncus brachiocephalicus with the left atrium (Figure 2F), and an extensive intrathoracic collateral network with a large paravertebral aneurysm (29 x 24 x 24 mm) of one of the collateral arteries arising from the left subclavian artery (Figures 3A, C, E). The large collateral artery aneurysm no longer showed any contrast opacification, likely reflecting spontaneous thrombosis secondary to the diminished collateral flow after the alleviation of the coarctation (Figures 3B, D, F).
Angiography of the aortic arch and descending aorta before (A) and after stent implantation (B). Angiography of the collateral artery aneurysm (C). DA, descending aorta; CoA, coarctation of the aorta; Stent, covered stent in the coarctation zone; CA, collateral aneurysm; LSA, left subclavian artery; LIMA, left internal mammary artery; Arch, aortic arch.
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F4
To treat the coarctation, a covered stent was implanted (Figures 4A, B) with good angiographic results and alleviation of the pressure gradient. Figure 4C shows the angiography of the collateral artery aneurysm that was subjected to conservative treatment.