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Pathophysiology

1. Aorta narrowed below origin of left subclavian artery and therefore blood flow to abdomen and legs is reduced
2. Prominent vessels over the back and large collaterals that have developed to bypass the obstruction supply the legs
3. Collaterals form between branches of the subclavian artery, especially internal mammary and scapular vessels 

Approach

• Expose back

1. Inspection
   • Large prominent tortuous blood vessels runing over the left scapula
2. Palpation
   • Demonstrate they are arteries
3. Percussion
4. Auscultation
   • Systolic bruits

Completion

1. Examine pulses of arms and legs (upper limb stronger than lower limb)
2. Patient usually hypertensive
3. Radio-femoral delay
4. Examine praecordium for ejection systolic murmur

Investigations

1. CXR: notching on the underside of ribs (erosion from intercostal vessels)
2. Barium swallow
3. Echocardiogram
4. CT / MRI

Associations of coarctation

• Bicuspid aortic valves
• Aortic stenosis
• Aneurysms of circle of Willis

Treatment options

1. Non-surgical
   • Investigation and treatment of abnormalities
   • Management of hypertension
2. Surgical
   • End-to-end anastamoses, patching and use of left subclavian artery as a flap