Rib Notching in Coarctation of the Aorta (Roesler’s Sign)

Coarctation of the aorta (CoA) is a rare cause of secondary high blood pressure (HBP); its diagnosis is important, since it is a potentially treatable etiology of HBP.CoA accounts for 6%-8% of all congenital heart disease, occurring as aortic arch stenosis proximal to the insertion of ductus arteriosus, below the origin of the left subclavian artery.(1, 2) CoA can occur as a solitary lesion, but is often associated with other cardiovascular lesions, including bicuspid aortic valve, aortic arch hypoplasia, mitral valve abnormalities, and ventricular and atrial septal defects.(1, 2) This is the case of a 39-year-old female patient with a history of HBP refractory to medical treatment, multiple therapy schemes with metoprolol, enalapril, valsartan, and hydrochlorothiazide, associated to recurrent headaches and coldness of the lower limbs; chest X-ray showed bilateral "notches" on the lower costal margins, or Roesler's sign (Figure 1).Cardiac Doppler ultrasound showed bicuspid aortic valve, normal left ventricular size and wall thickness, and preserved systolic function; cardiac CT-angiography of the chest revealed coarctation of the descending aorta posterior to the origin of the left subclavian artery, with prominent pulmonary arteries (Figure 2A).