Coarctation of the aorta in adults — SAQ

SAQ 1 (10 marks)

Practice scenario. A 26-year-old man is referred with hypertension found at a work medical. He reports headaches and occasional nosebleeds. His right-arm blood pressure is high and his femoral pulses are weak and delayed.^[1]

1. How would you measure his blood pressure at this first visit, and what findings indicate significant coarctation under ESC 2024 and ESC 2020? (2)
2. Which imaging should he have, and why is the Doppler gradient across the narrowing an unreliable guide? (2)
3. His upper-to-lower limb systolic gradient is increased, CMR shows an anatomically significant narrowing, catheterisation confirms a peak-to-peak gradient of 30 mmHg, and stenting is technically feasible. Give the ESC 2024 and ACC/AHA 2025 rows that apply, with class and level. (2)^[3][2]
4. Compare what ESC 2024 and ACC/AHA 2025 say about choosing a stent or surgery. (2)
5. Outline his follow-up after repair: blood pressure and aortic imaging. (2)

Model answers — SAQ 1

1. ACC/AHA 2025: measure blood pressure in all 4 extremities at the initial evaluation, then preferably in the right arm (except with an aberrant origin of the right subclavian artery) at every encounter (1 mark).^[2] ESC 2024: a systolic non-invasive gradient between upper and lower extremities, an abnormal ABI, or an invasive peak-to-peak gradient ≥20 mmHg indicates significant coarctation; ESC 2020 (dated) said a systolic gradient of ≥20 mmHg between upper and lower extremities indicates significant coarctation, as do weak or absent leg pulses or radiofemoral delay (1 mark).^[3][1]
2. ACC/AHA 2025: a new or suspected diagnosis should prompt TTE and cross-sectional imaging (CMR or CT angiography) to determine severity, arch anatomy and ascending aorta dimensions and to rule out intracardiac lesions; in unrepaired coarctation, cross-sectional imaging is recommended (COR 1, LOE B-NR) (1 mark).^[2] ESC 2024 says that with collaterals or decreased LV function, gradients or ABI may underestimate severity; ESC 2020 (dated) said Doppler gradients are not useful for quantification, in native or post-operative coarctation (1 mark).^[3][1]
3. ESC 2024: coarctation or re-coarctation repair (surgical or endovascular) is indicated in patients with hypertension with an increased non-invasive upper-to-lower limb gradient (decreased ABI) confirmed with invasive measurement (peak-to-peak >20 mmHg), with a preference for stenting when technically feasible (Class I, Level C) (1 mark).^[3] ACC/AHA 2025: in adults with native or repaired coarctation, surgical or transcatheter stent therapy is recommended for anatomically and hemodynamically significant coarctation to prevent irreversible LV dysfunction from chronic pressure overload (COR 1, LOE B-NR) (1 mark).^[2]
4. ESC 2024: in native coarctation and re-coarctation, covered stenting is the first-choice treatment, and interposition of a tube graft is the preferred surgical therapy if stenting is less suitable (1 mark).^[3] ACC/AHA 2025: immediate hemodynamic results are similar, but limited long-term data suggest more reintervention and less complete LV reverse remodeling after stenting; therapy should be individualised to anatomy, procedural risk and institutional expertise (1 mark).^[2]
5. Blood pressure (ACC/AHA 2025): resting upper and lower extremity measurement is recommended as part of routine clinical assessment to screen for hypertension and residual or recurrent coarctation (COR 1, LOE B-NR); ambulatory measurement is reasonable to diagnose hypertension and monitor response to antihypertensive therapy, and exercise testing is reasonable to screen for exercise-induced hypertension (both COR 2a, LOE B-NR); in native or repaired coarctation with hypertension without hemodynamically significant coarctation, GDMT for hypertension is recommended to maintain controlled resting and ambulatory blood pressure (COR 1, LOE B-NR) (1 mark).^[2] Imaging: ESC 2024 recommends lifelong follow-up with CCT/CMR of the aorta every 3–5 years, adapted to clinical status and previous imaging (Class I, Level B); after a stent, ACC/AHA 2025 says CT angiography should be used because of stent artefacts on CMR (1 mark).^[3][2]

Full marks need both points in each part: 2 marks per part, 10 in total.