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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Coarctation of the aorta

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Duct-dependent systemic collapse

Critical coarctation can become apparent as the arterial duct closes, causing grey colour, tachypnoea, weak femoral pulses, oliguria, metabolic acidosis, myocardial dysfunction and shock despite little cyanosis or a subtle murmur.

Action: Begin neonatal ABCDE resuscitation, call neonatal, paediatric cardiology and retrieval teams, obtain preductal and postductal saturations, four-limb pulses, blood gas, lactate, glucose, cultures and urgent echocardiography. Treat sepsis when plausible and start alprostadil through the regional duct-dependent pathway without waiting for imaging when clinical suspicion is high; use continuous monitoring, a dedicated line and an airway plan.

Synopsis

Recognise neonatal duct-dependent shock and later upper-body hypertension, confirm arch anatomy and associated disease, stabilise safely with prostaglandin when indicated, and provide lifelong surveillance after repair.

  • Coarctation is a congenital narrowing of the aorta, usually near the ductal insertion just beyond the left subclavian artery, causing upper-body pressure load and reduced lower-body flow.
  • Critical neonatal disease may depend on ductal flow to bypass the narrowing. Closure can precipitate shock after an initially normal examination and newborn screen.
  • Older children may present with right-arm hypertension, headaches, epistaxis, a systolic murmur over the left infraclavicular area or back, radiofemoral delay and reduced leg exercise capacity.
  • Examine simultaneous right brachial and femoral pulses, measure right-arm and leg blood pressure with correct cuffs, assess perfusion and palpate for collateral vessels; left-arm pressure can be misleading if the subclavian origin is involved.
  • Initial emergency tests are blood gas, lactate, renal and liver function, glucose, ECG and urgent paediatric echocardiography; do not delay stabilisation for a full imaging sequence.
  • Echocardiography defines the arch, gradient, duct, ventricular function and associated VSD or bicuspid aortic valve. MRI or CT maps the entire aorta in older children and during surveillance.
  • When duct-dependent obstruction is strongly suspected, start regional-protocol alprostadil and prepare for apnoea and hypotension; improving femoral pulses, lactate and acidosis indicate physiological response.
  • Surgery is usual in babies and young children. Balloon angioplasty or stenting is used selectively, especially in larger children, adolescents or recurrent narrowing.
  • Repair does not cure the arteriopathy: hypertension, recoarctation, aneurysm, bicuspid-valve disease and ascending-aortic dilatation can emerge later.
  • Lifelong congenital follow-up includes right-arm clinic and often ambulatory blood pressure, pulse and gradient assessment and periodic cross-sectional aortic imaging.

Key red flags

A previously well newborn developing poor feeding, lethargy, tachypnoea, oliguria or shock in the first days or weeks must have femoral pulses checked and critical coarctation considered.

Weak, absent or delayed femoral pulses, cool lower limbs or a reproducible right-arm to leg blood-pressure gradient indicates important arch obstruction.

Metabolic acidosis, rising lactate, renal or liver injury and left-ventricular dysfunction are signs of inadequate systemic output and require emergency transfer.

Normal pulse oximetry does not exclude coarctation because obstruction may impair systemic flow without producing a large right-to-left saturation difference.

Severe headache, neurological symptoms, chest or back pain, marked hypertension or collapse in an older child raises hypertensive emergency or aortic complication.

Persistent or recurrent hypertension, radiofemoral delay or exercise leg pain after repair suggests recoarctation or abnormal vascular function and needs specialist reassessment.

Investigation priorities

01
Immediate right-arm and leg pulse and pressure assessmentFirst step

Identify proximal-distal perfusion separation and grade emergency physiology.

Management branches

Neonatal emergencyRestore systemic flow

A newborn has weak femoral pulses, acidosis, oliguria or shock suggesting critical coarctation.

  1. Begin ABCDE support, obtain two vascular access points, monitor continuously and treat sepsis or hypoglycaemia when indicated.
  2. Discuss immediately with paediatric cardiology and start alprostadil through a dedicated line according to the regional presentation-based dose.
  3. Track palpable pulses, lactate and acidosis, prepare for apnoea and transfer urgently for surgical repair.
Stable childConfirm anatomy and hypertension

Radiofemoral delay, upper-limb hypertension or a suggestive murmur is found without shock.

  1. Repeat right-arm and leg measurements with appropriate cuffs and obtain paediatric echocardiography.
  2. Use MRI or CT when arch extent, collaterals or intervention planning requires cross-sectional definition.
  3. Refer through congenital cardiology for surgery, balloon treatment or stent according to age, size and anatomy.

Key medicines

Alprostadil infusion for suspected duct-dependent coarctationYorkshire neonatal protocol: if femoral pulses are poorly palpable but the infant is otherwise well and non-acidotic, start 25 nanograms/kg/min and double every 20 minutes to a maximum 100 nanograms/kg/min until pulses and lactate improve; an acidotic unwell infant starts 100 nanograms/kg/min with ventilation consideration.Use a dedicated primed line with continuous neonatal monitoring and urgent cardiology or intensive-care involvement. Apnoea, hypotension and fever are important; high doses commonly require mechanical ventilation, and line delay or tissue infiltration can silently interrupt lifesaving delivery.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • Leeds coarctation in childrenReviewed July 2026 UK presentation, repair and lifelong follow-up information.
  • Leeds neonatal alprostadil monographPresentation-specific prostaglandin dosing, monitoring and transfer precautions.
  • NHS Genomics coarctation knowledge hubNHS England clinical, genetic and management summary.
  • NHS congenital heart diseaseNational congenital heart disease overview.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom