Images in Clinical Medicine

Thromboatheromatous Aortic Coarctation

Abdolhamid Sheikhzadeh, M.D., and Hans B. Gehl, M.D.

N Engl J Med 1998; 338:1034April 9, 1998

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Article

Figure 1 A 53-year-old man with a family history of premature atherosclerosis, borderline hypercholesterolemia, and a 15-pack-year history of cigarette smoking was seen for intermittent claudication, which had been present for six months. On auscultation, the first heart sound was normal, A₂ was prominent, and P₂ was normal. There was a 2/6 ejection murmur over the upper part of the chest and a soft, continuous murmur over the intercostal area. There was no evidence of left or right ventricular failure. Blood pressure was 210/85 mm Hg in the right arm, 120/75 mm Hg in the left arm, and 110/75 mm Hg in the legs. The electrocardiogram showed normal sinus rhythm, left-axis deviation, and left ventricular hypertrophy. A chest film showed calcification of the aortic knob. Cardiac catheterization showed a normal left ventricular ejection fraction and normal coronary arteries; however, there was subtotal occlusion of the aortic arch and the left subclavian artery (arrows in Panels A and B). Computed tomographic (CT) scanning revealed subtotal occlusion and calcification of the aortic arch (arrow in Panel C). A secondary reconstruction of a primarily axial CT scan of a 4-mm-thick slice confirmed the presence of subtotal occlusion and calcification of the subclavian artery and the aortic arch. Four weeks after surgical removal of thromboatheromatous and calcified material from the aortic arch (Panel D), the variations in the blood-pressure measurements and the cardiac murmurs disappeared. Five months later the patient had no claudication. At that time, the patient was receiving aspirin and lipid-lowering drugs.

Abdolhamid Sheikhzadeh, M.D.
Hans B. Gehl, M.D.
University of Luebeck, 23538 Luebeck, Germany