3|Discussion
While surgery repair remains the first choice of treatment for coarctation of the aorta in infant and children, endovascular approaches like balloon angioplasty and stenting are increasingly employed in adult patients [4]. However, we did not recommend endovascular treatment for several reasons in this patient. Firstly, the patient’s twisted artery presented challenges in advancing a flexible guidewire across the coarctation. Secondly, this case involved not only aortic coarctation but also a concurrent aortic arch aneurysm, elevating the risk of rupture. Additionally, to minimize bleeding and maintain lower body blood supply, we opted for an extra-anatomical bypass instead of excising the coarctation and performing an end-to-end anastomosis.
Since Crafoord first surgical intervention to correct aortic coarctation in 1944[5], there have been significant advancements in surgical techniques, enhancing treatment quality and patient outcomes. Despite reduced mortality and morbidity rates, surgeries for aortic coarctation still pose considerable risks, including adverse events and patient morbidity. The presence of a concomitant aortic arch aneurysm in patients with aortic coarctation is exceedingly rare. Therefore, individualized patient assessments and meticulous planning are imperative for determining the most appropriate treatment strategy before undertaking such high-risk surgeries.
A major advantage of the extra-anatomic surgical approach is the durability in providing substantial distal blood flow to the mesentery and lower extremities. In a single-institution series of 50 patients undergoing ascending-descending aortic bypass for coarctation, there was no incidences of graft occlusion or pseudoaneurysm formation over an average follow-up of 33 months, with imaging evaluations conducted on 74% of the grafts[6].