An incidental finding of a pseudocoarctation of the aorta in a trauma patient: A case report and literature review

Introduction: Pseudocoarctation is an uncommon anomaly with different presentations that is primarily discovered with other abnormalities. Management is required with symptomatic patients. Case Report: In this paper we discuss a patient who was diagnosed incidentally and treated conservatively, followed by a brief literature review and discussion. Conclusion: Depending on the symptoms, surgical treatment with follow-up might be indicated.


INTRODUCTION
Pseudocoarctation of the aorta is an anomaly seen with hypoplastic aortic arch conditions and is under the similar disease spectrum.This condition is mainly seen in pediatric age groups.This can be misdiagnosed as the more commonly known lesion of cortication of the aorta, adding unnecessary investigations and a cost burden.Other congenital anomalies such as a ventricular septal defect and tetralogy of Fallot have both been associated with pseudocoarctation of aorta [1].Clinical symptoms may be absent at the time of diagnosis.In this case report we present an incidental finding of a pseudocoarctation of the aorta in a trauma patient with hypertension that was managed conservatively.

CASE REPORT
A 42-year-old male patient, with a past medical history of hypertension on lisinopril and dyslipidemia on a rosuvastatin, presented to the emergency department after a motor vehicle collision (MVC).He was a pedestrian hit by car.The primary survey was unremarkable except for a closed left fibula fracture.The secondary survey revealed facial lacerations.He denied abdominal pain and chest pain.The patient was taken for a trauma computed topography (CT) scan that included head, neck, spine, chest, abdomen, and pelvis.The CT scan was unremarkable except for an incidental congenital finding of kinking of the descending thoracic aorta which is in favor of pseudocoarctation of the aorta (Figure 1).He was admitted for observation and pain control.The facial lacerations were sutured with Prolen 4-0.A cardiology consultation was obtained and echocardiogram was performed.The echocardiogram showed an ejection fraction of 82%, a discrete stenosis of the aorta just distal to the origin of left subclavian artery with gradient of 45/23 mmHg consistent with the diagnosis (Figure 2).No sign of aortic stenosis or any other cardiac abnormalities were seen otherwise.The case was discussed with the cardiologist after the report of the echocardiogram.No intervention was decided.However, the recommendations were to continue with his home medication of an angiotensin converting enzyme inhibitor and a statin.The patient was subsequently discharged from the hospital for follow-up in the clinic.

DISCUSSION
Pseudocoarctation of the aorta is a rare congenital anomaly that might be associated with other abnormalities like ventricular septal defect (VSD), aortic stenosis, bicuspid aortic valve, and other cardiac abnormalities [1].It is described as kinking and narrowing of the aortic arch without causing obstruction [2].
The majority of the cases reported were diagnosed incidentally or via the recognition of other symptoms like hypertension or due to compression of surrounding structures.Symptomatic patients may present with chest pain, dysphagia, or signs of Horner's syndrome [3].One theory behind this condition goes back to the embryological development of the aortic arch.The compression of the third over the seventh dorsal segment is less than normal, resulting in a longer aortic arch that kinks at the level of ductus arteriosus [4].
The initial method of diagnosis should include an echocardiogram and a CT angiography to rule out other abnormalities and to verify the presence of the pseudocoarctation versus an actual coarctation of the aorta [4].Other authors recommend a magnetic resonance angiography (MRA) for diagnosis and follow-up.
As it was suggested by Gay et al., the criteria to diagnose pseudocoarctation of aorta include a small or absent gradient of less than 25 mmHg, no increase in the collateral vessels, an abnormal roentgenogram, and a definitive aortogram to confirm the diagnosis [5].The treatment of pseudocoarctation will depend on the presence or absence of any symptoms.If patients are symptomatic, surgical intervention is preferred especially with the presence of aortic aneurysm.Alternatively, patients can be treated conservatively when symptoms are lacking [3,6].
A pseudocoarctation of aorta can lead to an aortic aneurysm due to the increase in the turbulent blood flow in the post-stenotic part of the aorta [7].In these cases, the surgical treatment of choice is excision of the aneurysmal part of the aorta, and a close annual follow-up [8].Other surgical options include a replacement of the ascending aorta and a prosthetic aortic valve replacement [3].A case report by Shafaghi et al. was published about a young patient who had aortic aneurysm with an incidental finding of a pseudocoarctation post-trauma.The patient developed a massive hemothorax and underwent a left sided thoracotomy with excision of the aneurysmal part and an interposition graft insertion [9].Therefore, it is essential for patients with a pseudocoarctation to be careful with their daily activities and avoid certain type of sports that might cause rupture of the aorta.
In the past years, the preferred method for treating coarctation of aorta was with the use of balloon angioplasty, which showed a high rate of recurrence, hence it is now combined with stenting the aorta [10].From this approach, angioplasty and stent placement are considered another treatment option for patients with pseudocoarctation of aorta [11].

Figure 1 :
Figure 1: CT demonstrating kinking in the descending thoracic aorta, indicating pseudocoarctation of the aorta.

Figure 2 :
Figure 2: Echocardiogram confirming the diagnosis of pseudocoarctation of aorta with gradient of 45/23 mmHg.