Figure of 3-sign: a case report
The following appears in the journal European Heart Journal Case Reports.

A 50-year-old female was newly diagnosed with arterial hypertension and bilateral neck pulsations. Her current blood pressure was 170/100 mmHg in the right arm and 122 mmHg systolic in the right ankle. There was a radio-femoral delay palpable. The electrocardiogram showed signs of left ventricular hypertrophy.

On the chest X-ray, a figure of 3-sign was found at the aortic knuckle and notching of the inferior ribs was present. An echocardiogram revealed concentric left ventricular hypertrophy, a mildly stenotic bicuspid aortic valve, and a low peak-gradient across the descending aorta.

MRI demonstrated severe focal coarctation with complete interruption of the descending aorta. Large collaterals vessels were present, effectively bridging the aortic interruption.

In light of the extensive collateral vessels and the bleeding risk, an extra-anatomic aortic bypass was considered the least risky procedure. The patient agreed to the intervention and had an uncomplicated surgical course and recovery. At the 12-month follow-up, she was doing well and normotensive on Lisinopril 5 mg OD.

Learning points
• Aortic coarctation (CoA) is sometimes diagnosed in adult life.

• Clinical findings like an arm–leg blood pressure difference or typical chest X-ray signs may suggest an underlying diagnosis of CoA.

• A low peak gradient on echocardiography in the aortic isthmus does not exclude severe CoA.

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