Background <p>Coarctation of the aorta is a congenital cardiovascular anomaly characterized by aortic narrowing, typically presenting in early life. This report describes an exceptionally rare case of severe abdominal aortic coarctation with extensive collateral vessel formation in an asymptomatic 80-year-old male, underscoring the importance of recognizing delayed presentations and compensatory mechanisms. This report describes a case of severe abdominal aortic narrowing and significant compensatory dilatation of visceral arteries in an elderly male, along with a review of pertinent literature.</p> Case presentation <p>An 80-year-old Han Chinese male with a 10-year history of hypertension controlled with medical management (maximum blood pressure 150/90&#xa0;mmHg) was incidentally diagnosed with near-occlusion of the upper abdominal aorta during routine physical examination. Computed tomography angiography revealed severe stenosis of the abdominal aorta measuring 7 mm in diameter at its narrowest segment, accompanied by marked compensatory dilatation of the superior mesenteric, inferior mesenteric, and celiac arteries (maximum diameter: 1.4&#xa0;cm), forming extensive collaterals. Physical examination showed preserved dorsalis pedis pulses and no symptoms of ischemia. Given his asymptomatic status, advanced age, and robust collateral circulation, conservative management with ongoing surveillance was pursued.</p> Conclusion <p>This case illustrates the potential for advanced coarctation of the aorta to remain asymptomatic in elderly patients owing to compensatory vascular adaptation. It highlights the need for heightened clinical suspicion in patients with hypertension and individualized management strategies balancing risks of intervention against natural history.</p>