Because de novo lesions are rare in adults, most patients who are candidates for endovascular repair have had a previous intervention. Factors to be considered when deciding the most appropriate form of management include age, aortic morphology, any previous surgical or endovascular treatment, and the interventionist’s experience. Arch hypoplasia may cause a residual gradient following coarctation repair, particularly if it is severe and this condition represents a significant challenge for successful repair.

Approximately 10 % of patients who underwent surgical repair of neonatal aortic coarctation will develop recurrence as an adult and present with associated aortic diseases. Open repair can be challenging because of complex aortic pathology with the recoarctation, intercostal collateral circulation, and pleural scar tissue from the original operative approach.

Early repair of native coarctation is associated with a lower risk of late hypertension and improved survival, but the risk of recoarctation is higher. Recoarctation with aneurysm or pseudoaneurysm formation is fairly common. Aneurysms may develop at the site of surgical repair or within the proximal aorta and often these are best treated with endovascular therapy; aneurysmal disease distal to a recoarctation is fairly common. Untreated aneurysms carry a considerable risk of aortic rupture. With late repair, there is a greater risk of recurrent hypertension and a lower overall risk of recoarctation; nevertheless, survival and hypertension may still be improved by treating patients who are first diagnosed as adults.

The presentation of coarctation is dependent on the severity of obstruction and associated cardiac lesions; in general, those diagnosed as infants exhibit congestive heart failure, severe acidosis, and ischemia of the lower extremities. Adolescent and adult patients often present with ­hypertension that is difficult to control, headaches, nosebleeds, leg cramps, muscle weakness, claudication, ischemia of the bowel and lower extremities, and neurologic changes.

The goal of an endovascular approach to treat coarctation of the aorta is to restore anatomical relief of the obstruction resulting in reduction of the aortic gradient pressures. This concept is exemplified well in Fig. 42.1, which was contributed by one of my former fellows. Endovascular approaches are preferable to open surgery in the vast majority of patients with recoarctation, and balloon angioplasty and stent implantations are widely used [11, 16]; endoluminal grafting (including covered stents) may also be appropriate in selected cases [14]. Both covered and uncovered stents can be used to achieve satisfactory results. At our institution, we use endovascular techniques to provide relief from obstruction at the coarctation site and improve pressures proximally and distally as well as to exclude pericoarctation aneurysms or dissection to minimize the risk of rupture. The average duration of hospitalization following stenting of aortic coarctation is about 2 days, whereas open surgery may require a stay as long as 2 weeks. We strive to avoid disruption of blood flow to the left upper extremity and vertebral circulation, but when subclavian artery coverage is required, a carotid-subclavian bypass prevents vascular compromise to the left upper extremity. All patients with documented coarctation-associated pseudoaneurysms routinely undergo preoperative computed tomography (CT) angiography and Doppler studies to delineate the anatomical and physiological status of their carotid and vertebral arteries and its branches. If the operative procedure entails coverage of the left subclavian artery, we perform elective left carotid-subclavian bypass grafting whenever the right vertebral artery is abnormally small or diseased, or when there is evidence of an incomplete circle of Willis [12]. In the rare case in which the patient has had a left internal mammary artery bypass to the coronary circulation, the carotid-subclavian bypass is also necessary.