What is aortic coarctation? The aorta consists of three layers of structure called the intima, the media, and the ecta. The so-called aortic coarctation occurs when the intima of the aorta is torn for various reasons, and arterial blood flow enters the middle of the aortic wall through this tear, thus separating the aortic wall. The blood flow extends distally and proximally along the aortic wall and can involve the entire length of the thoracic aorta and even the abdominal aorta and its branches. Therefore, aortic coarctation is so devastating that it has been called a “catastrophic disease” of the aorta. If the original lumen of the artery is called the true lumen, the lumen formed by the separation of the mesentery is the false lumen. The false lumen and the true lumen are like the layers of a “sandwich”, and rupture can be life-threatening. This is why we often compare aortic coarctation to a life-threatening “sandwich”. What are the causes of aortic dissection? The causes of aortic coarctation are complex, and some common causes include hypertension, diabetes, atherosclerosis, trauma, medical injury, pregnancy, inflammation, genetic factors (Marfan’s syndrome), and cystic lesions in the middle layer of the artery. Of these, hypertension is the most important. Patients with Marfan’s syndrome What is the risk of aortic dissection? Aortic coarctation is rapid and destructive. In the acute stage, it can cause aortic rupture and ischemia of organs and limbs leading to death, while in the chronic stage, the aortic coarctation can gradually expand to form a coarctation aneurysm. As the diameter of the aneurysm increases, the patient’s entrapment aneurysm will eventually rupture and lead to death. What are the clinical manifestations of aortic coarctation? 1, chest pain: 90% of the patients in the onset of aortic coarctation will appear sudden severe pain in the chest, back or abdomen. The pain often occurs when making some sudden movements, such as lifting heavy objects, playing basketball, or even yawning, coughing, straining to defecate, etc. The pain is cutting or tearing. The pain is cutting or tearing, severe, and radiates distally from the back of the sternum or back of the chest. The site of pain initiation often suggests the site of the entrapment rupture. The patient is often irritable, sweats profusely, has a sense of near death, and may faint from the pain. Patients who survive from the acute phase, chest pain gradually disappears or turns to hidden pain. 2.Hypertension: it is the most common sign in patients with aortic coarctation. Firstly, most of the patients with this disease have the basis of high blood pressure, and secondly, the formation of the sandwich will in turn further increase the blood pressure. 3. Rupture: Hemorrhage caused by rupture is the main cause of death from coarctation. When rupture occurs, in addition to the severe chest pain mentioned above, there are hemorrhagic shock manifestations such as drop in blood pressure, pallor, cold sweat, cyanosis and other special manifestations: rupture into the esophagus manifests as vomiting blood, rupture into the trachea manifests as hemoptysis, rupture into the pericardium manifests as pericardial tamponade, and rupture into the thorax manifests as respiratory distress, and so on. 4, organs and limbs ischemic performance: in addition to rupture, another harm of the entrapment is to affect the blood supply of the aortic branch vessels, including the brain, heart, intestines, kidneys, lower limbs, etc., which can cause ischemia, dysfunction and even functional failure of these organs. Commonly, there are cerebral infarction, cardiac infarction, abdominal pain, jaundice, blood in stool, oliguria or anuria and severe ischemia of lower limbs. How is aortic coarctation diagnosed? A variety of special tests can be used to diagnose aortic coarctation. For example, a chest X-ray can show enlargement of the aortic bulb and widening of the mediastinum, but a chest X-ray cannot be used as a definitive diagnosis of coarctation. Enhanced CT is commonly used to diagnose aortic coarctation. It is safe, simple, accurate and economical. Therefore, enhanced CT has important value in both diagnosis and preoperative evaluation of aortic coarctation. Magnetic resonance angiography (MRA) is also a good method to diagnose aortic coarctation, but the MRA image is slightly blurred, especially in the measurement of the internal diameter of blood vessels is not precise enough. Transesophageal ultrasound (TEE) is a safe, non-invasive, sensitive and specific method to diagnose aortic coarctation, which can make a diagnosis of aortic coarctation very accurately and quickly. The disadvantage is that the operation cannot be successfully completed in patients with unstable condition in the emergency department, and there is a certain limitation in observing the arches and their branching blood vessels due to the interference of the trachea. Meanwhile, TEE cannot observe abdominal aortic coarctation and fissure. Digital subtraction angiography (DSA) is an effective means of diagnosing aortic coarctation, but because it is invasive and expensive, DSA technology is more often used in the endoluminal treatment of aortic coarctation. DSA imaging How is the traditional surgical approach performed? The traditional treatment is to perform an artificial vascular replacement, specifically, the patient is put under general anesthesia, the chest is opened (some patients have to open the abdomen at the same time), the extracorporeal circulation is established, the coarctation aneurysm is dissected out, the diseased and damaged aortic segments are resected, and then the artificial blood vessels are anastomosed with the relatively normal aorta at both ends of the aneurysm, to restore the aorta’s blood flow, and sometimes it is necessary to reconstruct multiple branching blood vessels. Depending on the degree of difficulty, the duration of the operation ranges from 4 hours to more than 10 hours, with significant bleeding and blood transfusion. Because of the complexity of the surgery, the long duration of arterial blockage, and the enormous trauma, it has a direct impact on the patient’s heart, lungs, brain, kidneys, and other vital organs. Post-operative period is prone to many complications such as heart attack, brain infarction, respiratory failure, kidney failure and so on. What is more unfortunate is that aortic coarctation aneurysms usually occur in the middle-aged and elderly population, and most of them are coexisting with different diseases such as hypertension, coronary artery disease, diabetes mellitus, pulmonary and renal hypoplasia etc., which makes the surgery more dangerous, and many patients lose the chance of treatment due to their inability to tolerate the surgery. How does endoluminal treatment work? The aim of endoluminal treatment of aortic coarctation is to prevent rupture of the aneurysm and to improve blood supply to the organs. Instead of opening the chest or abdomen, the procedure is performed through a small incision 3-5 cm long at the base of the thigh. Under X-ray fluoroscopy, a delivery device with grafts (stent vessels) is introduced from the femoral artery, and when it reaches the diseased aorta, the grafts are released and fixed by propping them up against the aortic wall at both ends of the fissure, thus closing the fissure and preventing the continuous impact of the high velocity of blood on the pseudo-cavity. What are the advantages of endoluminal repair? Compared with traditional open heart and open abdomen surgery, the most outstanding features of endoluminal repair are its simplicity, minimally invasive and effective treatment. Because the treatment is less invasive, the operation time is shorter, and the blood transfusion is less, the patient recovers quickly after the operation. In general, patients can eat and drink normally and get out of bed 24 hours after surgery. These features provide an opportunity to treat many elderly and frail patients with multiple coexisting diseases who cannot tolerate traditional surgery. Therefore, endoluminal repair has been called a revolution in the history of aortic coarctation treatment. Does a successful endoluminal treatment give patients peace of mind? Aortic coarctation often has multiple breaches, with the first breach usually in the isthmus of the descending aorta and multiple breaches distal to it, and often next to important visceral arteries. Endoluminal treatment involves covering the first breach with a stent-type artificial blood vessel to prevent blood from continuing to enter the false lumen, lowering the pressure inside the false lumen and causing blood clots to form inside the false lumen, with the aim of healing the false lumen. However, sometimes blood continues to flow into the false lumen from the distal breach, and even though the pressure has been lowered considerably, the distal false lumen is still at risk of rupture due to the continued increase in size of the false lumen. Therefore, it is critical that patients undergo regular follow-up after successful endoluminal treatment of aortic coarctation. If the distal coarctation is still present and growing, surgery may be required. What should patients pay attention to after surgery? 1.Control the blood pressure and heart rate by taking oral antihypertensive drugs regularly as prescribed by the doctor, keep the blood pressure within normal range (systolic blood pressure not higher than 140mmHg, diastolic blood pressure not higher than 90mmHg), and especially avoid fluctuation of blood pressure. Heart rate control within 80 times / min; 2, improve lifestyle, moderate exercise, avoid strenuous exercise, low-salt, low-fat light diet, avoid emotional excitement, active control of blood lipids and blood glucose; 3, strictly in accordance with the doctor’s instructions to take antiplatelet, statin and other medications; 4, postoperative 3 months, 6 months, 1 year to find a professional doctor to do aortic augmentation CTA on a regular basis.