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History: S/P device occlusion of PDA 3weeks ago (4/2 Abbott/Amplatzer Piccolo occluder delivered prograde)Progressive DAO obstruction with upper extremity HTN and increasing gradient both by BP cuff and by

TTE (gradient 25-35mmHg), diminished femoral artery pulses, Ongoing severe RDS and intolerance of steroid treatment due to aortic arch obstruction.

Procedure: Surgeon performed RCCA cutdown.4 Fr Terumo Slendersheath advanced to aortic arch, angio done by congential cardiologist. Findings: Angiographically patient found to have severe coarctation of the aorta unmasked by Piccolo device closure of PDA. transverse arch is good sized and there is severe discrete isthmic coarctation of the aorta in addition to the aortic retention skirt of the Piccolo device at the coarctation. Decision to stent-36200, 37236. The RCCA sheath was removed, the carotid ateriotomy was repaired, and the cutdown incision was closed by the CV surgical team.