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A 60 year old man was referred for diagnostic evaluation of severe right arm hypertension and suspected aortic coarctation. Hypertension and a systolic murmur were diagnosed when he was 20 years old. The patient suffered from a stroke a few months before admission. Physical examination revealed a grade 3/6 systolic murmur at precordium radiating to the mid back, and weak and delayed femoral pulses. Blood pressure was 185/90 mm Hg in the right arm and 130/75 mm Hg in the left arm. The chest x ray revealed rib notching caused by congestive collateral circulation. Thoracic magnetic resonance (MR) angiography demonstrated an extreme coarctation at the isthmus of the aorta, and a tight ostial stenosis at the origin of the left subclavian artery originating from the stenotic segment. The left internal mammary artery appeared hypertrophic and tortuous (left panel). Catheterisation showed a mean pressure gradient of 60 mm Hg across the coarctation. Angiography confirmed the MR diagnosis (right panel).