Aortic coarctation is an uncommon etiology for adult-onset hypertension. Few cases in the modern literature have been reported with lower thoracic aortic coarctation as a cause for hypertension. A 36-year-old woman who had been treated for 12 years with progressive hypertension presented to her local emergency room with worsening dyspnea on exertion and acute onset of left-sided chest and upper limb pain. Evaluation for myocardial infarction was negative; however an echocardiogram revealed concentric left ventricular hypertrophy with severe global dyskinesia and an ejection fraction of 35%. Cardiac catheterization and aortography identified a lower thoracic aortic coarctation with a 90 mm Hg gradient and mild abnormalities of the coronary arteries. There was no evidence of involvement of the visceral or renal arteries. After stabilization of her blood pressure with nipride, nitroglycerin, and esmolol, she underwent a left posterolateral thoracotomy for aortic repair using an interposition Dacron graft. Operative findings showed no evidence of arteritis. Pathologic examination of a removed portion of the aorta revealed severe calcific atherosclerotic vascular disease and fibrosis in the adventitia with no evidence of active inflammation. The patient was quickly weaned from intravenous antihypertensive medication postoperatively and eventually discharged after a normal convalescence with diminished hypertension. © 1999, Sage Publications. All rights reserved.