Coarctation of the Aorta with Regression of Rib Notching Following Surgery

Abstract

The notching of the inferior aspect of the ribs as a result of pressure from the tortuous vessels of the collateral circulation in coarctation of the aorta is one of the best known diagnostic signs in medicine. Since the advent of improved surgical technics, the operation for correction of the coarctation has become increasingly common. Consequently, opportunity is now available to follow this and other diagnostic signs in the postoperative stages. A case is presented here in which the coarctated segment was resected and x-ray examination one year later showed improvement in both the sharp angular and smooth broad types of rib erosion. Case history A white male, age 14 years, was admitted to the University of California Medical Center Outpatient Department on Aug. 20, 1951, with a diagnosis of coarctation of the aorta made by the referring physician. The early history revealed only that a cardiac murmur had been heard at the age of five years. At ten years, there was hypertension in the arms, but the blood pressure in the legs was not measured. Physical examination on admission showed excellent general physical development. Arterial pulsations in the neck were forceful. The blood pressure in the right arm was 180/100, left arm 100/100, right leg 90/0, left leg 80/0. The lungs were clear. Examination of the heart revealed no evident cardiac enlargement to percussion, regular sinus rhythm, and a loud, slapping aortic second sound. A harsh systolic murmur was audible at the left 2nd and 3rd intercostal spaces, transmitted through to the back. No pulsations could be felt in the lower extremities. The remainder of the physical examination was within normal limits. X-ray examination of the chest, on Aug. 27, showed notching of the inferior aspects of the 2nd through the 8th ribs (Figs. 1A, 2A, 3A). The cardiac contour and the lungs were not remarkable. On Oct. 3, 1951, surgery was carried out. Coarctation of the aorta was found immediately distal to the take-off of the left subclavian artery at the level of the ligamentum arteriosum. The diameter of the aortic lumen at this point was about 1.0 mm. Proximal to the coarctation the diameter was definitely less than distal to it. The subclavian artery was large, and the internal mammary artery was particularly large. The intercostal collaterals were providing the blood supply to the distal aorta. The coarctated segment was excised and an end-to-end anastomosis between the proximal and distal aortic segments was accomplished. Postoperative recovery was uneventful. The blood pressure in the right arm was 170/110 following surgery, and good femoral pulsations were present. One year following surgery the blood pressure in the right arm was 150/95, in the left arm 130/95, in the right leg 145/100, and in the left leg 145/110. The supraclavicular vessels were prominent, and their pulsations were felt. A systolic murmur could be heard over the precordium.