Ductal aneurysm with postsubclavian coarctation of aorta in an adult.

We describe a case of ductal aneurysm in an adult patient with post subclavian coarctation of aorta, which is a very rare association.

A 41-year-old male with coarctation of aorta and systemic hypertension was evaluated with computed tomography (CT) angiography followed by cardiac catheterization and angiography, to assess the anatomy and pressure gradient. CT angiography demonstrated postsubclavian coarctation with minimum lumen diameter of 10.8 mm × 11.2 mm and focal anterior bulging of immediate coarctation segment and no collaterals [Figure 1]. Catheterization study showed pullback gradient of 24 mmHg across the coarctation segment. Aortic angiography confirmed postsubclavian coarctation with focal anterior bulging of immediate postcoarctation segment in the region of ductus arteriosus (DA) forming ductal aneurysm size of 23 mm × 20 mm [Figure 2].

Figure 1

(a and b) Computed tomography scan showing discrete postsubclavian coarctation of aorta with focal anterior pouching of ductus – ductal aneurysm

Figure 2

Aortic angiogram with marker pigtail in situ. (a) In lateral view, the discrete postsubclavian coarctation of aorta with focal anterior bulging of the ductus forming ductal aneurysm. (b) The dimensions. (c) posteroanterior view. Arrow marks showing ductal aneurysm

Ductal aneurysm is a focal outpouching at the arterial end of DA. It is a rare condition and usually presents in neonatal age group. In a series of 24 cases of neonatal ductal aneurysm, Dyamenahalli et al. found that most are isolated entities and only seven had associated syndromes such as Marfan syndrome, Smith–Lemli–Opitz syndrome, trisomies 21 and 13, and Ehlers–Danlos syndrome.[1] Hayashi et al. described a ductal aneurysm rapidly developing to a coarctation of aorta in a neonate.[2] It is rare in adulthood and its association with adult coarctation has never been reported. DA closes from its pulmonary end, and nonobliteration of aortic end of DA leads to the formation of ductal diverticulum. With subsequent transmission of high systemic pressures, it may enlarge to ductal aneurysm.[3] Usually, it possess an obtuse angle with aortic wall with smooth margin.[456] In the described patient as the coarctation is of moderate severity, the relatively high distal aortic pressure could have enlarged the ductal diverticulum to an aneurysm. On the contrary, if it was a tight coarctation, such large ductal aneurysm may not have been developed. This may be the reason for ductal diverticulum or aneurysms not being commonly reported with coarctation of aorta.

The most common differential diagnosis is aneurysmal dilation of the poststenotic segment of coarctation, which tends to be fusiform dilatation.

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