A 13-year-old male presented to our hospital after sustaining injuries from a motor vehicle accident (MVA). The patient had bee sitting unrestrained in the front passenger seat of a car when he met with the accident. He had been found unconscious inside the car. Upon arrival in the emergency room, he regained consciousness. As part of the trauma protocol, the patient underwent a full-body CT, which revealed moderate subgaleal hematoma, small hemorrhagic brain contusion, multiple lung contusion, and moderate-size pseudoaneurysm in the descending aorta just distal to the left subclavian artery (LSCA) with associated mediastinal hematoma (Figure ).\nThe CT scan also revealed hepatic, right renal, and splenic lacerations without any evidence of active bleeding. Multiple fractures in the ribs, sternum, right femur, and tibia were also observed. The patient was subsequently admitted to the pediatric intensive care unit (ICU). After a combined surgical and cardiac team discussion, and in the view of other stable lesions, the decision was made to proceed with treating the aortic pseudoaneurysm with impending rupture first. Because of the presence of intracerebral haemorrhage and visceral organ lacerations, the patient was deemed at high risk for systemic anticoagulation required for an operative aortic repair. Available percutaneous endograft sizes were deemed too large for his descending aortic diameter, and the associated potential risk of vessel injury from the large sheath required to implant the endograft removed this option from consideration. The decision was made to attempt percutaneous implantation of a balloon-expandable covered stent across the pseudoaneurysm in the cardiac catheterization laboratory. Under general anesthesia, the right femoral artery access was obtained, and an 11 French (Fr) sheath was inserted. A pigtail catheter was advanced to the transverse aorta, and an angiogram was performed (Figure ).\nThe angiogram revealed a diameter of 14 mm at the mid-aortic arch, descending aorta immediately after the pseudoaneurysm, and aorta at the level of the diaphragm. The length of the disrupted aortic segment was 22 mm, and it was 10 mm away from the origin of the LSCA. Based on the angiogram measurements, a 16x38 mm BeGraft aortic stent, which is a balloon-expandable covered stent, was used successfully. This was followed by post-stenting dilation with short non-compliant 17 x 30 mm Z-Med balloon (B. Braun, Melsungen, Germany). There was no residual aneurysmal filling, and comparison pressures demonstrated no significant gradient from ascending to descending aorta (Figure ).\nThe patient was transferred in stable condition to the pediatric ICU for further management. His post-catheterization course was uneventful. Subsequently, he underwent several orthopaedic procedures until he was discharged home in good condition.
A 17-year-old male with no previous medical illness was admitted to the hospital with abdominal pain. The patient had a long time history of generalized intermittent abdominal pain that increased postprandial without nausea or vomiting. The patient also had a history of fatigue on exertion. Upon checking vital signs, the patient was found to be hypertensive. There was a discrepancy between the upper (155-160/70-75 mmHg) and lower limbs (100-105/65-70 mmHg) readings. Cardiovascular examination showed a systolic ejection murmur best appreciated at the tip of the left scapula, and bracheo-femoral delay. The abdominal examination was unremarkable. His complete blood count, renal profile, liver profile, troponin, and brain natriuretic peptide were normal. Stool analysis and culture were normal. Electrocardiography revealed sinus rhythm and left ventricular (LV) hypertrophy (Figure ). The chest X-ray revealed the classic rib notching sign (Figure ). An echocardiogram revealed a BAV with mild to moderate aortic regurgitation and dilatation of ascending aorta (Figure ). A post-ductal CoA was observed with a systolic gradient of 80 mmHg (Figure ). His LV function was normal with mild eccentric hypertrophy. Cardiac CT was done and confirmed severe post-ductal CoA with extensive collaterals (Figure ). Another incidental finding was a left-sided IVC, which courses anterior to the abdominal aorta between the aorta itself and superior mesenteric artery crossing the midline to the right before joining the right renal vein and the intra-hepatic IVC segment (Figure ). The patient was discussed in a heart team meeting, and it was decided to proceed with transcatheter intervention with stenting.\nThe procedure was done under general anesthesia through the right femoral access. The pre-stenting peak gradient was 60 mmHg, which improved to 4 mmHg using 14 x 39 mm BeGraft aortic stent (Bentley InnoMed, Hechingen, Germany), which is a balloon-expandable covered stent. This was followed by post-stenting dilation with short non-compliant Z-Med balloon (B. Braun Interventional Systems, Bethlehem, PA) (Figure ). No temporary pacing was used for stenting. No periprocedural complications were encountered. The patient stayed in the hospital for two days, then was eventually discharged home on losartan 100 mg daily. Six weeks later, the patient was called for follow up. His symptoms resolved utterly, and blood pressure was well controlled.