In Reply.—The comments of Giroud and colleagues are a welcome addition to the list of diagnostic pitfalls in CoA and recommendations on how to avoid them. No one can disagree that a thorough clinical examination is preferable to a cursory one. We doubt, however, that blood pressure measurements in both upper extremities in all children will ever become an accepted routine. We therefore emphasize careful palpation of upper- and lower-extremity pulses and blood pressure measurement at least in the right upper extremity as a part of first-time examination of an asymptomatic child. In the case Giroud and colleagues report, the referring physician noticed the prominent pulse in the left arm and, as a result, made appropriate blood pressure measurements.
Aberrant origin of subclavian arteries makes the clinical presentation of CoA atypical and makes its recognition more difficult. Cases of "pulseless disease" due to aberrant origin of one or both