[Primary diagnosis of an interrupted aortic arch in a 65-year old woman with hypertension].

HISTORY AND PHYSICAL EXAMINATION: A 65-year-old woman presented in a hypertensive crisis and with angina pectoris. She had a history of hypertension for several years and medication included five different antihypertensive drugs. On physical examination a faint systolic murmur was heard. Weak femoral pulses were felt, but not the arterial pulses distal to the groin.

INVESTIGATIONS: An attempt to perform coronary arteriography failed because it was impossible to pass the catheter across the aortic arch. MR-angiography and cardiac catheterization via the brachial artery confirmed the diagnosis of a complete interruption of the aortic arch distal to the left subclavian artery and showed distinct collateral circulation predominantly via the internal mammary arteries.

DIAGNOSIS AND THERAPY: Because of the age of the patient we assumed that the pathogenesis of this interruption of the aortic arch probably was progression and finally occlusion of an aortic coarctation. It was not possible to distinguish the findings from a true congenital atresia, because there was no histological examination. The patient rejected surgery and conservative therapy with frequent monitoring seemed justified, considering the good blood pressure adjustment and the extensive collateral vascularization.

CONCLUSION: Patients with complete interruption of the aortic arch very rarely do reach late adult age without previous surgical intervention. Indeed, such a situation is only conceivable when there is a good collateral blood supply and no concomitant shunt defects. There is an indication for operation, but as there are insufficient follow-up data this should be weighed up carefully in elderly patients whose blood pressure is well controlled.