The Calcified Barrier: A Rare Cause of a Distal Aortic Arch Stenosis.

BACKGROUND

Calcification of the aortic arch is common, but an intraluminal calcified plaque causing functional stenosis is rare. At the distal arch, it mimics aortic coarctation, with refractory upper-body hypertension and left ventricular pressure overload.

CASE SUMMARY: A 61-year-old man presented with refractory hypertension despite 4 agents and recurrent hypertensive cardiac decompensation with an upper-to-lower-limb blood pressure gradient. Computed tomography angiography showed a high-grade calcified stenosis of the distal arch (peak gradient 70 mm Hg; left ventricular ejection fraction 30%). The lesion was resected en bloc and the arch reconstructed with a frozen elephant trunk prosthesis under selective cerebral perfusion. Recovery was uneventful; the gradient resolved and left ventricular ejection fraction improved to 45% at 6 months.

DISCUSSION: Coral reef obstruction of the arch is rare, lacks management guidelines, and is easily mistaken for congenital coarctation or Takayasu arteritis.

TAKE-HOME MESSAGE: When rigid calcification precludes endovascular therapy, en bloc resection with frozen elephant trunk reconstruction offers a safe and durable repair.