Ruptured descending aortic aneurysm as a complication of childhood coarctation repair A 48-year-old man was found unconscious with an unrecordable blood pressure. He responded very well to fluid resuscitation. He had a 2-week history of progressive left-sided pleuritic chest pain, radi- ating into his left arm, and episodes of small-volume haemoptysis. There were no infective symptoms. Apart from cigarette smoking, he had no risk factors of venous thromboembolism. His past medical history was only significant for aortic coarctation repair at the age of 6 when he underwent a resection of coarctation and anastomosis without the use of a patch graft. He was unfortunately lost to follow-up as an adult. On examination, he was diaphoretic, hypotensive and tachycardic. Heart sounds were dual and chest auscultation revealed minimal air entry into the left lung. Computed tomography (CT) pulmonary angiography revealed a large saccular aortic aneurysm arising just proximal to the origin of the left subclavian artery measuring 7.4 cm ¥ 7.5 cm ¥ 7.1 cm. It was associated with a large left-sided haemothorax. The left lower lobe was collapsed, likely a result of compression of the left main bronchus between the thoracic aortic aneurysm and pulmonary trunk. There was no evidence of aortic dissection (Fig. 1). A chest drain was inserted. He then underwent an endoluminal repair of his ruptured aneurysm. Two GORE TAG thoracic endoprostheses (W.L. Gore & Associates, Flagstaff, AZ, USA) were deployed from the proximal descending thoracic aorta, clear of the origin of left common carotid artery, extending to the mid descend- ing thoracic aorta (Fig. 2). Balloon moulding was performed to the distal, proximal and overlapping segments of the grafts. The left subclavian origin was covered but was seen to fill via collateral vessels. It was decided not to proceed to subclavian artery ligation or carotid-subclavian bypass. A repeat CT angiogram of the chest showed stable size of the left haemothorax and no extravasation of contrast from the grafts (Fig. 3). Following this, an evacuation of the left haemothorax via video-assisted thoracic surgery was performed. The patient’s post- operative course was unremarkable and he was discharged 12 days after his endovascular aneurysm repair. He was referred for regular outpatient follow-up. Coarctation of the aorta occurs in approximately 4 in 10 000 live births and represents 5–8% of all congenital cardiac defects. 1 Fig. 1. Large saccular aneurysm arising at the origin of the left subclavian artery, with a large left-sided haemothorax. Left basal pigtail drain in place. Fig. 2. Angiogram demonstrating two endoluminal stent-grafts deployed in the distal aortic arch and descending thoracic aorta, showing exclusion of the aneurysm. IMAGES FOR SURGEONS ANZJSurg.com © 2013 The Authors ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons ANZ J Surg 83 (2013) 186–187