1109 Huge aortic aneurysm after surgical repair of coarctation
Authors: De La Torre Carpente M M , Redondo Bermejo B , Perez Sanz T M , Acuna Lorenzo M A , Revilla Martinez M I , Tapia Ballesteros C , Rollan Gomez M J 
Published: January 2020

Abstract

A 51-year-old male presented to hospital with hemoptysis. The patient had been diagnosed of coarctation of the aorta and aortic aneurysm distal to the coarctation. In 1998 he underwent surgical correction with a a left subclavian artery bypass to the descending thoracic aorta and the aneurysm was excluded with a dacron graft. He denied hypertension.
A thoracic CT performed during this episode, revealed a huge aneurysm in the descending thoracic aorta with a maximal transverse diameter of 13 cm and anteroposterior diameter of 13 cm. The length of the aneurysm was 11.5 cm. Inside the aneurysm there was a big thrombus with several peripheral layers of calcium. The vessel lumen had a diameter of 5.5 cm. The subclavian bypass had no stenosis. The right subclavian artery had an aberrant origen. The aneurysm compressed the left atrium, the left pulmonary artery, left lung tissue and the left main bronchus with a segmentary compressive atelectasis. There was a "ground-glass" pattern in the posterior region of the left superior lobe suggesting pulmonary bleeding. There was no evidence of enlargement of bronchial arteries. Neither were bronchiectasis.
Thus, the patient was diagnosed of high suspicion of fistula between aorta and bronchi of the left superior lobe. He was referred to a centre specializing in treatment of coarctation and he was offered a debranching plus TEVAR procedure. Open surgery was not an option due to high risk. The patient refused the intervention.

Discussion
adults with aortic coarctation should undergo intervention when the gradient across the coarctation is greater than or equal to 20 mmHg and there is hypertension, when there is an altered blood pressure response during exercise or in case of hypertrophic left ventricle. Treatment options are surgery, stent and balloon angioplasty. Complications following intervention include recoarctation, aortic aneurysm, aortic dissection and hypertension. Therefore, it is mandatory to follow up these patients closely and regularly after an intervention either surgical or percutaneous.
Digging up in our patient history we found a previous CT in 2009, at that moment transversal diameter of the aneurysm was 9.4 cm and the anteroposterior 12.4 cm. There were no more data after 2009 till 2019.
Aortic aneurysms are a rare cause of hemoptysis with a very bad prognosis if not treated. Though CT and MR may suggest that there is a fistula, the aortography is the gold standard technique. Another mechanisms related to hemoptysis are the rupture of small vessels because of the compression of lung tissue or bronchial collapse with subsequent infection. In this case, maybe the big thrombus helped to avoid the rupture of the aneurysm into the left bronchi which would be fatal.

Conclusion
Patients with repaired coarctation of aorta should be followed regularly, whatever procedure is performed, because some of the complications following repair can have a bad prognosis.
Abstract 1109 Figure. hugeaneurysmEuroEcho2019