This case involves a 15-year-old female patient who presented to her PCP for an unrelated complaint. The PCP auscultated a heart murmur and referred the patient to a pediatric cardiologist. A TTE diagnosed a coarctation of the aorta. Days later, a CTA was performed to better visualize the aortic arch. The cardiothoracic surgeon interpreted the study as showing a lesion at the arch between the innominate and L carotid and recommended a more complex surgery to repair the lesion instead of a simple repair of the coarctation. A month later, the patient underwent surgery involving a median sternotomy under deep cardiac arrest instead of simple left throacotamy for simple coartation repair. In the post-operative period the patient suffered pulmonary embolism which migrated to her brain. She is now left with marked dystonia and other neurologic deficits. It was not until 6-months post-op that the CTA was interpreted by a pediatric radiologist, confirming 60% coarctation of the aorta with no abnormality of the aortic arch. This case takes place in the state of Utah.