Navigating Mechanical Support in Cardiogenic Shock With Arterial Hypoplasia: Lessons From Arterial Tortuosity Syndrome.

We present the case of a 19-year-old man admitted with cardioembolic stroke and rapidly evolving cardiogenic shock as the first manifestation of arterial tortuosity syndrome (ATS). Severe biventricular dysfunction, extreme left atrial enlargement, and new-onset atrial fibrillation explained the embolic event. However, the management was dominated by the profound arterial abnormalities characteristic of ATS. Marked hypoplasia and tortuosity of the iliofemoral arteries (3 mm), ascending aorta (19 mm), and thoracic aorta rendered both mechanical thrombectomy and peripheral VA-ECMO implantation technically unfeasible. Multimodality imaging, cranial CTA, aortic angiography, and cardiac MRI were essential in defining procedural risk and ruling out vascular access options. A temporary intra-aortic balloon pump was selected as the only feasible mechanical support strategy, allowing clinical stabilization. Finally, genetic testing confirmed a pathogenic SLC2A10 variant consistent with ATS. This case highlights the importance of detailed vascular imaging in young patients with shock and unexplained vascular anatomy and illustrates how arterial hypoplasia can directly limit life-saving interventions.