Bharadwaj Prashant, Wasir Amanpreet Singh, Passwala Hemali, Patil Vaibhav
Department of Cardiology, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India.
Heart Views. 2024 Oct-Dec;25(4):260-263. doi: 10.4103/heartviews.heartviews_64_24. Epub 2025 May 10.
Endovascular stenting has emerged as the preferred treatment modality for coarctation of the aorta (CoA). However, CoA can sometimes extend beyond the aortic arch, involving adjacent vessels such as the left subclavian artery (LSA), which complicates conventional interventions. We present a case of CoA associated with proximal LSA stenosis which was successfully treated using a double-wire stent technique. The technique does not compromise the LSA flow and offers a promising alternative in complex CoA cases. A 19-year-old female presented with palpitations with dyspnea (New York Heart Association grade III) for 15 days. She also gave a history of intermittent claudication in the left upper limb for 3 years. Clinical examination revealed pallor and weak pulses in the left upper extremity and both lower extremities, with radio-radial and radio-femoral delays. Blood pressure measurements indicated significant gradients between the limbs, with readings of 244/112 mmHg in the right upper limb, 162/104 mmHg in the left upper limb, and 114/74 mmHg and 116/78 mmHg in the right and left lower limbs, respectively. Auscultation revealed normal S1 and S2 and a systolic murmur in the right interscapular area. Electrocardiogram revealed sinus arrhythmia with T-wave inversions in leads II, aVF, and V1-V6. Echocardiogram revealed severe postductal coarctation with a gradient of 84 mmHg. Computed tomography aortography confirmed a severe coarctation-preductal diameter of 12 mm and postductal diameter of 14 mm, with a concomitant LSA stenosis of 7 mm. The critical challenge in this case was stenting the coarctation without compromising the already symptomatic LSA stenosis. A novel endovascular approach was employed, utilizing two preplaced wires in both the aorta and LSA, followed by deployment of an uncovered stent and final kissing balloon angioplasty. This is the first instance in literature of such an approach being taken. Patients with CoA with associated bifurcation stenosis of the LSA are extremely rare and pose significant challenges for endovascular management. This case highlights a novel and effective interventional strategy, offering a tailored approach to preserve LSA patency while addressing the complex CoA anatomy.
血管内支架置入术已成为主动脉缩窄（CoA）的首选治疗方式。然而，CoA有时可延伸至主动脉弓以外，累及相邻血管，如左锁骨下动脉（LSA），这使得传统干预措施变得复杂。我们报告一例与近端LSA狭窄相关的CoA病例，该病例采用双导丝支架技术成功治疗。该技术不会影响LSA血流，为复杂CoA病例提供了一种有前景的替代方法。一名19岁女性因心悸伴呼吸困难（纽约心脏协会III级）就诊15天。她还自述有3年左上肢间歇性跛行病史。临床检查发现左上肢和双下肢苍白且脉搏微弱，桡动脉与桡动脉、桡动脉与股动脉搏动延迟。血压测量显示双下肢之间存在明显压差，右上肢血压为244/112 mmHg，左上肢为162/104 mmHg，右下肢为114/74 mmHg，左下肢为116/78 mmHg。听诊显示S1和S2正常，右肩胛间区有收缩期杂音。心电图显示窦性心律失常，II、aVF及V1 - V6导联T波倒置。超声心动图显示导管后严重缩窄，压差为84 mmHg。计算机断层扫描主动脉造影证实严重缩窄——导管前直径12 mm，导管后直径14 mm，同时LSA狭窄7 mm。该病例的关键挑战在于在不影响已出现症状的LSA狭窄的情况下对缩窄部位进行支架置入。采用了一种新颖的血管内方法，在主动脉和LSA中预先放置两根导丝，随后置入裸支架并进行最终的球囊对吻血管成形术。这是文献中首次采用这种方法。伴有LSA分叉狭窄的CoA患者极为罕见，给血管内治疗带来了重大挑战。本病例突出了一种新颖且有效的介入策略，提供了一种在处理复杂CoA解剖结构的同时保留LSA通畅的定制方法。
