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.
A 46-year-old lady underwent CT chest abdomen and pelvis for breast cancer staging. The CT was reported as free of secondary pathology; however, the below-discussed findings were observed.\nThe CT scan shows the infrarenal tract of the IVC localised on the left side of the aorta. This left paramedian IVC is of normal calibre and crosses the middle line at the level of the celiac trunk, behind the aorta (). At T 12, the IVC continues its way up to the chest as Azygos vein, passing through the aortic hiatus of the diaphragm. No embryologic remnants of the supracardinal veins are noted on the right side of the aorta. A large vein is located ventromedially to the ureter on both sides, consistent with large ovarian veins. Furthermore, the right renal vein follows an anomalous course, as it is situated posteriorly to the aorta to drain into the left-sided IVC. Finally, a partial duplication of the left ureter is noted ().