Endovascular Management of an Occluding Thrombus in the Thoracic Aorta: An Uncommon Complication after Open Surgery for Aortic Coarctation

Objectives: Coarctation of the aorta (CoA) is a relatively common congenital defect that accounts for 5 to 8% of all congenital heart defects. The most common complications following coarctation repair include recoarctation, aortic aneurysm or dissection, premature coronary atherosclerosis, cerebrovascular accidents and systemic hypertension.

Methods: We present an unusual case of a 51 male presenting with acute flaccid paraplegia 32 years after CoA repair due to a total thrombotic occlusion of the thoracic aorta.

Results: A 51-year-old male was referred to our center due to abrupt paraplegia that occurred during physical strain. In the age of 18 years the patient underwent open surgery for aortic coarctation through a left lateral thoracotomy using a 16-mm Dacron graft. Due to the neurological deficits, a head CT was performed to exclude a stroke or cerebral hemorrhage. Subsequently coldness and pallor in the lower extremities as well as the absence of the femoral and dorsal pedis arterial pulses were detected. CT angiography of the thoracic and abdominal aorta was performed revealing thrombotic occlusion of the descending Thoracic aorta, starting immediately after the branch of the left subclavian artery . Decision was made for endovascular treatment because open surgery was considered to be more difficult owing to dense scarring in the region of the previous repair and a higher risk of neurologic complications due to missing collaterals. During intervention, a 21 × 100 mm GORE Stentgraft could be placed just behind the branch of the left subclavian artery. Postoperative course was uneventful and the neurological deficits completely disappeared. The patient was discharged home under oral anticoagulation with phenprocoumon 13 days after intervention.

Conclusions: The present case is intended to sensitize treating physicians for this uncommon complication hardly reported before and encourage them to perform a systematic preoperative examination including pulse status and a neurological examination in order to not overlook a symptom and to initiate a therapy without loss of time. Cardiovascular surgeons should be aware of this problem and the possible therapeutic approaches. The treatment of such complex cases requires the expertise of various specialists in the fields of cardiology, radiology, cardiovascular surgery and hematology, so that treatment in large centers is recommendable.