Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation

During the 35 month period ending December 1987, 30 children, aged 14 days to 13 years, underwent balloon angioplasty of unoperated aortic coarctation with resultant reduction in coarctation gradient from 43.6 +/- 20.4 to 9.5 +/- 7.6 mm Hg (p less than 0.001). None of the patients required immediate surgical intervention. On the basis of results of 6 to 30 month follow-up catheterization data in 20 children, the patients were classified as follows: Group A, 13 patients with good results (gradient less than or equal to 20 mm Hg and no recoarctation on angiograms) and Group B, 7 patients with fair or poor results (gradient greater than 21 mm Hg with or without recoarctation on angiography). No patient developed aortic aneurysm at the site of angioplasty. Thirty variables were examined by multivariate logistic regression analysis and four factors were identified as risk factors for development of recoarctation: 1) age less than 12 months, 2) aortic isthmus less than 2/3 the size of the ascending aorta immediately proximal to the right innominate artery, 3) coarcted aortic segment less than 3.5 mm before dilation, and 4) coarcted aortic segment less than 6 mm after angioplasty. The identification of risk factors may help in selection of patients for balloon angioplasty. Avoiding or minimizing the number of risk factors may help reduce the chance of recoarctation after angioplasty. The intermediate-term follow-up results with regard to recoarctation are comparable with those after surgical repair of coarctation. Recoarctation after angioplasty was dealt with by repeat balloon angioplasty or surgical resection for those requiring treatment and clinical follow-up for the remaining children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon angioplasty for coarctation of the aorta: immediate and long-term results

Twenty-five infants and children with native coarctation of the aorta had percutaneous balloon angioplasty over a 28-month period ending in May, 1987. The mean systolic pressure gradient across the coarctation decreased from 47.6 +/- 20.9 mm Hg to 10.3 +/- 7.3 mm Hg (p less than 0.001) following angioplasty, and the diameter of the coarcted segment increased from 3.2 +/- 1.7 mm to 7.8 +/- 3.5 mm (p less than 0.001). Clinical and echo-Doppler follow-up indicated excellent results in 16 of the 18 patients in whom 3- to 22-month follow-up was available; two infants required additional treatment (repeat angioplasty in one and surgical resection in the other). Fourteen patients who underwent repeat cardiac catheterization remain improved with regard to pressure gradient across the dilated coarctation (9.5 +/- 9.6 mm Hg, p less than 0.001) and angiographically measured sizes of the coarcted segment (10.3 +/- 3.2 mm, p less than 0.001). No aneurysm was seen in any child. We recommend balloon angioplasty as the therapeutic procedure of choice for relief of severe, previously unoperated coarctation of the aorta in neonates and young infants. Routine use of balloon angioplasty for unoperated coarctation of the aorta in children appears indicated, but should await longer follow-up results and reports of follow-up on a larger number of patients; this caution is mainly based on reports from other workers of aneurysm formation at the site of balloon dilatation.     

Balloon angioplasty for native aortic coarctation.

From May 1987 to August 1990, eighteen patients underwent balloon angioplasty for native aortic coarctation. The age of the patients ranged from four to fifty six years (mean age 17.5 years). The procedure was successful in all cases with a reduction in the peak gradient across the coarctation from 61 +/- 19 mm Hg to 11.7 +/- 8.1 mmHg (p < 0.05). The coarcted segment increased from 4.5 +/- 1.9 mm to 10.7 +/- 3.9 mm (p < 0.05). Peak gradient at six to twelve months follow up, obtained in ten patients, was 19.8 +/- 10.1 mmHg (p = NS). There were no life threatening complications, although seven patients had local vascular problems after the procedure. In two patients, there was persistence of hypertension necessitating drug therapy. On haemodynamic and angiographic restudy in 10 patients, one patient had restenosis and none had aneurysm formation. We conclude that balloon angioplasty is a safe, and less invasive alternative to surgery for native aortic coarctation with gratifying immediate and short term results.     

Remodeling of the aorta after successful balloon coarctation angioplasty

The purpose of this study was to examine whether remodeling of the aorta takes place after successful balloon angioplasty of aortic coarctation. During the 35 month period ending in December 1987, 30 children, aged 14 days to 13 years, underwent balloon angioplasty of unoperated aortic coarctation, with a resultant reduction in mean coarctation gradient from 44 +/- 20 to 10 +/- 8 mm Hg (p less than 0.001). On the basis of results of 6 to 30 months' follow-up catheterization data in 20 children, the patients were classified into group A (13 patients with good results; gradient less than or equal to 20 mm Hg and no recoarctation on angiography) and group B (7 patients with fair or poor results; gradient greater than 20 mm Hg with or without recoarctation on angiography). Measurements of the aorta at five sites (the ascending aorta, isthmus, coarcted segment and descending aorta distal to the coarctation and at the level of the diaphragm) were made in two angiographic views, corrected for magnification and averaged. A standardized diameter of the aorta at the five locations was calculated for each case before angioplasty and at follow-up study, and variance of the diameter was then determined. The variance of standardized aortic measures (0.233 versus 0.287) was similar (p greater than 0.05) in both groups before angioplasty, whereas at follow-up study (0.057 versus 0.129) they were different (p = 0.01). There was a greater percent improvement at follow-up study (0.233 versus 0.057) in the group with good results than in the group with fair or poor results (0.287 versus 0.129).(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous balloon angioplasty for native coarctation of the aorta

Twenty-six children, aged 5 weeks to 14.7 years, underwent percutaneous balloon angioplasty for a discrete native coarctation of the aorta. The procedure reduced the systolic coarctation gradient acutely in all children. The mean systolic gradient decreased by 75%, from 48.6 +/- 2.4 before to 12.3 +/- 1.9 mm Hg after angioplasty (p less than 0.001). Long-term results were evaluated in 14 children by follow-up catheterization 12 to 26 months (mean 15.3) after angioplasty. At follow-up, the residual gradient averaged 11.7 +/- 3.7 mm Hg (range -5 to 36) and had not changed from that measured immediately after angioplasty (p = 0.64). Compared with preangioplasty values, the systolic pressure in the ascending aorta had improved substantially at follow-up (116.0 +/- 3.2 versus 143.9 +/- 3.1 mm Hg, p less than 0.001). On the basis of follow-up data, two groups of children were identified: Group 1 consisted of nine children with a good result, defined as a residual gradient less than 20 mm Hg and no aneurysm; Group 2 consisted of five children with a poor result, four with a residual gradient greater than 20 mm Hg (range 25 to 36) and one with an aneurysm at the dilation site. There was no statistical difference between the two groups in age at angioplasty, balloon size, ratio of balloon to isthmus diameters, follow-up duration, heart rate or cardiac output. However, of the four children with a residual gradient greater than 20 mm Hg, two were the youngest in the study, and in two the aorta was inadvertently dilated with a balloon 4 to 5 mm smaller than the isthmus diameter.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon coarctation angioplasty: follow-up of 103 patients

OBJECTIVE: To evaluate the role of balloon coarctation angioplasty (BCA) in the management of patients with native coarctation of the aorta. BACKGROUND: BCA has emerged as an alternative to surgery for patients with native coarctation of the aorta. However, its role remains controversial. METHODS: Over a 7-year period, 103 patients undergoing BCA were enrolled in the study. Hemodynamic evaluation was obtained at baseline and immediately following BCA; 75% of patients returned for follow-up evaluation at 26 +/- 20 months. RESULTS: The systolic gradient across the coarcted segment decreased from 59 +/- 18 mmHg to 10 +/- 11 mmHg following BCA (p < 0.001). The procedure was successful in 82% of patients, and partial improvement was obtained in 17%. Repeat intervention was performed in 13% of the follow-up group. Surgical intervention was needed in 8 patients. CONCLUSION: Balloon angioplasty is an effective first-line intervention in patients with native coarctation of the aorta.     

Percutaneous angioplasty of native coarctation of the aorta. Results in children and young adults

The authors report the experience of one centre in the treatment of native coarctation of the aorta by percutaneous angioplasty. Between 1999 and August 2005, 22 patients (7 girls, 15 boys) underwent dilatation of their coarctation by a balloon catheter at an average age of 11.8 +/- 5 years and body weight of 44 +/- 21 kg. In 20 patients, balloon angioplasty alone was performed and, in the other two, the angioplasty was associated with the insertion of a covered CP stent. The dilatation was performed with a balloon/coarctation ratio of 2.18 +/- 0.6 (1.7 to 3.5) and a balloon/isthmus ratio of 1.0 +/- 0.23 (0.7 to 1.87). After the procedure, ascending aortic pressure decreased from 134.7 +/- 23.4 mmHg to 125 +/- 22.7 mmHg (p= 0.0003); descending aortic pressure increased from 93.4 +/- 14.9 mmHg to 104.8 +/- 21.7 mmHg (p= 0.003); transisthmic pressure gradient decreased from 41.7 +/- 14.1 mmHg to 19.8 +/- 9.5 mmHg (p< 0.0001) and the diameter of the coarctation increased from 5.9 +/- 2.6 mm to 9.3 +/- 2.6mm (p= 0.0015). The two patients treated by covered CP stents had excellent immediate results without significant residual gradients. After dilatation (sometimes repeated, N= 13), a gradient > 20 mmHg persisted in ten patients (36% of cases) but no predictive factor was found on statistical analysis. There were no cases of acute aneurysm. In one patient, the femoral pulse decreased but returned to normal with heparin therapy. No patient required emergency surgical treatment after the angioplasty. During the clinical follow-up, echocardiography and MRI showed no signs of aneurysm and one patient had mild irregularity of the isthmic region. Three patients underwent surgery by resection suture for persistent coarctation (one combined with a Ross procedure); another patient was treated by a CP stent. In conclusion, percutaneous angioplasty of native coarctation of the aorta gives satisfactory results with few complications in bigger children and young adults. The results can be improved by using a slightly higher balloon/coarctation ratio.     

Congenital aortic coarctation in children treated by percutaneous transluminal balloon angioplasty (8 cases)

Balloon angioplasty was performed in eight patients aged 3-12 years (mean 7.5) with coarctation of aorta (CoA). Seven children did not undergo operation before, while one patient had re-stenosis after surgical repair of the CoA. Immediately after angioplasty, the mean systolic pressure gradient was reduced from 7.8 +/- 2.8 to 1.7 +/- 1.1 kPa and the CoA diameter increased from 3.9 +/- 1.7 to 9.0 +/- 1.8 mm. Follow-up study of 2-18 months showed a continuing gradient decrease in seven of eight patients. No aneurysm was found in this series, probably related to the appropriate balloon size. Our data suggest that balloon angioplasty is a safe and effective method in relief of the stenosis by congenital membranous aortic coarctation and postoperative restenosis of the coarcted aorta.     

Balloon angioplasty of native coarctation of the aorta in adolescents and young adults.

Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 +/- 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the post-coarctation aorta. The peak systolic pressure gradient decreased from 78.5 +/- 23.9 to 15.7 +/- 11.6 mm Hg (p less than 0.001), and the mean coarctation diameter increased from 4.7 +/- 2.4 to 13.1 +/- 2.7 mm (p less than 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 +/- 10.7 vs 27.2 +/- 6.6 mm Hg, p less than 0.01). On recatheterization and angiography in 26 patients at 12.6 +/- 1.5 months after dilatation, there was no significant change in gradient (15.5 +/- 13.3 mm Hg) and diameter (13.1 +/- 1.8 mm) from the immediate post-angioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms with no change in appearance on restudy after 2 years. After 3 to 67 months' (mean 32.7 +/- 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12/32) and improved in 59.4% (19/32). Our experience suggests that balloon angioplasty of native aortic coarctation in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up.     

Surgical repair is safe and effective after unsuccessful balloon angioplasty of native coarctation of the aorta.

Since 1985 balloon angioplasty, followed by surgical repair if angioplasty is unsuccessful, has been used as a treatment strategy for eligible children with discrete native coarctation of the aorta. Although balloon angioplasty has been successful in most patients, this strategy is appropriate only if surgery is safe and effective in children in whom angioplasty does not succeed. To address this issue, the surgical procedure and clinical outcome in 11 children who underwent surgery after unsuccessful balloon angioplasty (defined as a residual systolic gradient greater than 20 mm Hg in 10 and a saccular aneurysm in 1) were evaluated. Data for subjects were compared with data for a control group of seven children who had surgical repair of a discrete coarctation without prior angioplasty during the same time period. In the study group, balloon angioplasty was performed at 4.3 +/- 1.2 years of age, resulting in a balloon/isthmus ratio of 0.98 +/- 0.05 and decreasing mean peak systolic gradient from 54 +/- 3 to 27 +/- 2 mm Hg (p less than 0.001). Follow-up angiography (n = 7) or nuclear magnetic resonance imaging (n = 4) documented a discrete residual stenosis in 10 patients and a small saccular aneurysm in 1. Collateral circulation decreased in three patients. The subsequent surgical procedure and its outcome were similar in the study and control groups. Chylothorax was the only complication, occurring in one child from each group. No paraplegia or mortality occurred. Pathologic examination revealed irregular intimal surfaces with small flaps of intima in 5 of 10 resected specimens from the study group and in 2 of 6 from the control group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Balloon dilatation for discrete subaortic stenosis: immediate and intermediate-term results

Six children with subvalvar aortic stenosis underwent percutaneous balloon angioplasty over a 15-month-period ending October 1989. The mean systolic pressure gradient across the left ventricular outflow tract decreased from 56 +/- 19 (mean +/- SD) to 12 +/- 7 mmHg (p less than 0.001) immediately following valvuloplasty and the degree of aortic insufficiency did not significantly increase. Follow-up Doppler data (in all 6 patients) were available 3 to 16 months (mean, 11 months) after angioplasty and revealed a residual aortic subvalvar gradient of 21 +/- 5 mmHg, which continues to be significantly lower (p less than 0.001) than that prior to angioplasty. There was no increase in aortic insufficiency. The single infant with increase in gradient at followup was determined to have fibromuscular, tunnel type of subaortic obstruction. None of the five patients with discrete membranous obstruction had significantly increased their gradients. Use of balloons larger than aortic valve anulus did not produce any adverse effect, particularly aortic insufficiency. We surmise that the immediate and intermediate-term follow-up results of balloon angioplasty are encouraging and balloon angioplasty should be considered as a treatment option in the initial management of discrete subaortic membranous stenosis.     

Percutaneous transluminal valvuloplasty of pulmonary stenoses. Apropos of 35 cases

Thirty-five patients with moderate or severe valvular pulmonary stenosis underwent percutaneous transluminal valvuloplasty (PTV). The average age of the patients was 12 years (range 4 to 34 years). Sixty per cent were under the age of 10, 20 p. 100 were between 10 and 17 years old and 20 p. 100 between 18 and 34 years old. Systolic right ventricular pressures were greater than the pressures in the systemic circulation in 22 cases. The right ventricular-pulmonary artery pressure gradient was greater than 50 mmHg in 29 patients and less than or equal to 50 mmHg in the other 6 patients. The diameter of the balloon of the dilation catheter varied from 12 to 20 mm in 31 PTV; in the other 4 cases two dilating catheters were used simultaneously to dilate the pulmonary valves. The tolerance of PTV was generally good and the results were satisfactory: right ventricular pressures (RVP) fell from 140 +/- 45 to 77 +/- 25 mmHg (p less than 0.001); the RV-PA pressure gradient fell from 82 +/- 40 to 32.4 +/- 15 mmHg (p less than 0.001) and the ratio of RVP to systemic pressure from 1.2 +/- 0.4 to 0.65 +/- 0.2 (p less than 0.01). Clinical and haemodynamic reevaluation in 19 patients 4 to 16 months after PTV (mean 8.5 +/- 2 months) showed that RVP, RV-PA pressure gradients and RVP/systemic pressure ratios had significantly decreased respectively from 78 +/- 30 to 52 +/- 14 mmHg (p less than 0.001), from 27.7 +/- 7.7 to 21.8 +/- 7.3 mmHg (p less than 0.02) and from 0.6 +/- 0.2 to 0.4 +/- 0.1 (p less than 0.001). Pulmonary valvuloplasty is well tolerated, safe and may reduce the number of patients requiring surgical valvotomy.     

Success determining factors in percutaneous transluminal balloon valvuloplasty of pulmonary valve stenosis

Twenty-two percutaneous transluminal balloon valvuloplasty procedures were performed on 21 patients with congenital pulmonary valve stenosis. The peak systolic pressure gradient was immediately reduced from 79.1 +/- 7.4 to 22.2 +/- 1.8 mmHg, (P less than 0.0001) and follow-up cardiac catheterization at 5.3 +/- 0.4 months in 19 patients revealed no further significant change in gradient (23.5 +/- 3.2 mmHg). The best results were obtained when balloons larger than the pulmonary annulus were used, i.e. an immediate residual transvalvular gradient of 22.0 +/- 2.2 mmHg with a balloon/annulus ratio greater than 1, as opposed to 44.2 +/- 5.4 with a balloon/annulus ratio = 1 (P less than 0.001). The angiographically determined cusp thickness of the stenotic pulmonary valves was significantly greater than that of the control group of 24 patients without pulmonary valve stenosis (1.21 +/- 0.09 vs 0.59 +/- 0.02 mmHg, P less than 0.00001). The relationship between this parameter and the residual transvalvular gradient at follow-up was found to be significant (r = 0.77, P less than 0.001). It is concluded that balloon size is a determinant factor in achieving good results with percutaneous balloon valvuloplasty although cusp thickness, a factor to which scant regard has hitherto been paid, also plays a significant role in the residual transvalvular gradient measured at follow-up.     

Aortic isthmus stenoses--dilatation in adulthood. A German cooperative study

An analysis of percutaneous transluminal angioplasty of the coarctation of the aorta in adults was evaluated in a cooperative study of the German Working Group of Angioplasty of the German Society of Cardiology. Dilation was performed in 18 patients with a mean age of 26 years (14-49 years). The success rate (gradient less than or equal to 20 mm Hg) was 78% regarding peak to peak gradient, 89% regarding mean gradient. The peak-to-peak gradient decreased from 82 +/- 16 mm Hg to 18 +/- 11 mm Hg. The diameter of the aortic isthmus increased from 0.7 +/- 0.3 cm to 1.3 +/- 0.4 cm (p less than 0.01). After six months only one restenosis occurred. The peak-to-peak gradient measured 10 +/- 12 mm Hg, the diameter 1.4 +/- 0.5 cm. In two patients a balloon rupture occurred without rupture-related complications. No patients died, no cross paralysis or aortic rupture occurred. In three of seven patients with trans-esophageal echocardiographic monitoring a small intimal flap was found; in one patient a media dissection occurred leading to a 15-min period of chest pain and spontaneous healing. In another patient successful dilation was controlled by acute control aortography and computer tomography. After discharge severe chest pain developed. A subtraction angiography of the aorta was negative. Six months later a biplane aortography of the distal thoracic aorta confirmed the diagnosis of aortic dissection type III DeBakey, previously diagnosed by transesophageal echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)     

Right coronary artery occlusion: its role in the mechanism of precordial ST segment depression

To investigate the mechanism of precordial ST segment depression during right coronary artery occlusion, precordial ST segment shifts and myocardial lactate metabolism were evaluated during coronary angioplasty in 10 patients with (group A) and 7 patients without (group B) precordial ST segment depression during balloon occlusion of the right coronary artery, and in 17 patients with precordial ST segment depression during balloon occlusion of the left anterior descending artery (group C). A 12 lead electrocardiogram was continuously recorded in each patient. Blood lactate in the aorta and great cardiac vein was measured during the procedure, and the lactate extraction ratio in the anterior wall was determined both before and during balloon occlusion. Eight of the 10 patients in group A and 1 of the 7 patients in group B had a dominant large right coronary artery. There were no significant differences in summed ST segment elevation in leads II, III and a VF between group A (0.56 +/- 0.26 mV) and group B (0.46 +/- 0.19 mV) during balloon occlusion of the right coronary artery, and no significant differences in summed ST segment depression in leads V1 to V6 during balloon occlusion between group A (0.44 +/- 0.26 mV) and group C (0.38 +/- 0.14 mV). Lactate extraction ratio before balloon occlusion was similar among the three groups. Patients in group A had a higher lactate extraction ratio during (38 +/- 11%) compared with before (30 +/- 11%) (p less than 0.05) balloon occlusion despite precordial ST segment depression.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of balloon size and stenosis morphology on immediate and delayed elastic recoil after percutaneous transluminal coronary angioplasty.

After successful coronary angioplasty, the minimal luminal diameter of the dilated coronary artery segment is generally smaller than the diameter of the largest balloon catheter at the maximal inflation pressure. The determinants of this phenomenon were studied in 28 patients. Biplane angiograms were obtained after intracoronary administration of isosorbide dinitrate (1 mg) before, immediately and 24 h after coronary angioplasty. Balloon and coronary luminal diameters were measured by automated contour detection. Immediately after the procedure, the difference between inflated balloon diameter and minimal luminal diameter averaged 0.93 +/- 0.43 mm for the entire group and was greater both in eccentric stenoses (1.13 +/- 0.39 vs. 0.70 +/- 0.36 mm; p less than 0.01) and after angioplasty with an oversized balloon (1.20 +/- 0.37 vs. 0.71 +/- 0.33 mm; p less than 0.005). At 24 h, the balloon - minimal luminal diameter difference was unchanged at the group level (0.86 +/- 0.38 mm, but the minimal luminal diameter increased significantly in the subgroup of coronary segments dilated with an oversized balloon (1.97 +/- 0.37 vs. 1.81 +/- 0.28 mm; p less than 0.05). Thus, the difference between the minimal diameter of a dilated coronary segment immediately after a successful coronary balloon angioplasty procedure and the maximal diameter of the inflated balloon catheter is dependent both on eccentricity of the stenosis and on the balloon/artery diameter ratio. Moreover, the increase in minimal luminal diameter 24 h after angioplasty performed with an oversized balloon suggest that in addition to elastic recoil partly reversible factors related to vessel barotrauma are involved.     

Importance of balloon size in coronary angioplasty

The effect of balloon size on the success of coronary angioplasty was studied to develop quantitative criteria for optimal selection of balloon size. Coronary dimensions of 165 stenotic lesions were measured by computer-assisted cinevideodensitometry in 120 patients who had undergone angioplasty with a balloon selected by visual estimates. Cross-sectional areas and diameters of normal and stenotic arterial segments were measured before and after angioplasty by a previously validated cinevideodensitometric technique. The diameter of the inflated balloon compared with that of the normal arterial segment was expressed as a ratio for sizing balloons. Oversized balloons with a ratio greater than 1.3 (n = 35) caused a high (37%) incidence of dissection, with three severely compromised arterial lumens. Undersized balloons with a ratio less than 0.9 (n = 29) often resulted in significant (greater than 50% diameter stenosis) residual stenotic lesions (21%) and a significantly (p less than 0.05) higher rate of repeat angioplasty for restenosis. Selection of balloon sizes with ratios in the 0.9 to 1.3 range (n = 101) resulted in a low (4%) incidence of dissection with few patients (3%) having significant residual stenosis. Mean residual stenosis (percent diameter reduction) was most severe for undersized (35.0 +/- 18%) or oversized (23.1 +/- 19%) balloons and least severe for balloons with a ratio of 0.9 to 1.3 (18.7 +/- 14%) (p less than 0.001). Repeat angioplasty for restenosis was more frequently required (p less than 0.05) for lesions dilated with undersized balloons. Thus, selection of angioplasty balloons that approximate or slightly exceed the diameter of the normal arterial diameter yields optimal angiographic results with minimal dissections and minimal residual stenotic lesions.     

Angiographic follow-up after balloon angioplasty for coarctation of the aorta

Balloon angioplasty for coarctation of the aorta was performed in 45 patients; 17 (Group 1) were infants (mean age 34 +/- 43 days). This study focuses on the remaining 28 patients (Group 2), children and adults ranging in age from 2 to 31 years (mean 13 +/- 8). Two patients had had previous surgery for coarctation; in the remaining 26 the coarctation had not been surgically treated. Twenty patients (71%) had a discrete type of coarctation; the remaining eight had a diffuse or eccentric stenosis. Angiographic studies of the aorta were performed before and immediately after angioplasty in all 28 patients; 16 (57%) of them also underwent angiographic reevaluation 10 +/- 2 months later. The pressure gradient decreased immediately after angioplasty and was unchanged at follow-up. Residual gradient at follow-up ranged from 0 to 40 mm Hg (mean 11 +/- 13). Patients with a discrete type of coarctation had a lesser residual gradient than did patients with other anatomic types of coarctation. Angiographically, the stenosis also decreased after angioplasty (68 +/- 10% versus 24 +/- 17%; p less than 0.01); a new small, but significant decrease was observed at follow-up (9 +/- 18%; p less than 0.05). A quantitative analysis of the aorta at different levels revealed no significant changes proximal and distal to the coarctation segment; however, at the level of coarctation, a significant (p less than 0.01) and homogeneous increment was observed after dilation that was unchanged at follow-up. One (6%) of 16 reevaluated patients had a clear aneurysm at the site of dilation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transcatheter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation.

Twenty two children (age range 4 months-20 years) with pulmonary valve stenosis and ten children (age range 1 month-11 years) with coarctation of the aorta underwent balloon dilatation in the 29 month period between October 1983 and February 1986. Number 5-9 French catheters with 5-20 mm balloons were used according to the size of the angiographically measured pulmonary valve annulus or coarcted segment and the aorta proximal to coarctation. The peak inflation pressure used in the balloons varied from 2-5 atm (202-505 kN/m2) for pulmonary valve stenosis and 4-8 atm (404-808 kN/m2) for coarctation, and inflation lasted 8-15 s. At least four balloon dilatations were performed in every case. After balloon dilatation the mean (SD) peak systolic pressure gradient across the pulmonary valve fell from 98 (39) to 33 (13) mm Hg. The cardiac index did not change. After balloon dilatation of aortic coarctation the systolic pressure in the descending aorta rose from 86.4 (17.7) to 107.8 (20) mm Hg and the peak systolic pressure difference across the coarctation fell from 44.1 (19.1) to 8.5 (8.5) mm Hg. The diameter of the angiographically measured coarcted segment increased, the Doppler estimate of the pressure difference across the coarctation decreased, and the femoral pulses improved. There were no important complications. Long term follow up results for balloon dilatation of pulmonary valve stenosis were excellent. Similar follow up was not available for patients after dilatation of aortic coarctation. Percutaneous balloon dilatation for pulmonary stenosis and coarctation of the aorta is a safe and effective alternative to operation. It is the treatment of choice for pulmonary valve stenosis and it may become so for coarctation of the aorta in young children if long term results are favourable.     

Results and mid-long-term follow-up of stent implantation for native and recurrent coarctation of the aorta.

AIMS: Since the late 1980s, endovascular stents have been used in the treatment of several vascular lesions. In the last decades, stent implantation has been proposed as a reliable option for the treatment of coarctation of the aorta. In this setting, it seems to have some advantages, rendering it superior to angioplasty alone. METHODS AND RESULTS: Between December 1997 and December 2004, 71 consecutive patients (44 males and 27 females) underwent cardiac catheterization for native or recurrent coarctation of the aorta. Seventy-four stents were implanted. All discharged patients were enrolled in a follow-up programme. Every patient underwent clinical evaluation, echo-colour Doppler studies, and exercise ECG at 1 and 6 months after the stent implantation. Peak systolic gradient dropped from 39.3 +/- 15.3 to 3.6 +/- 5.5 mmHg (P = 0.0041). The diameter of the coarcted segment increased from 8.3 +/- 2.9 to 16.4 +/- 3.8 mm (P = 0.037). In our series, one death occurred in a 22-year-old girl with a recurrent coarctation of the aorta, just after stent implantation. The rate of minor complications was <2%. Re-dilatation of a previously implanted stent was performed in three patients. CONCLUSION: In our experience (the largest reported to the best of our knowledge), stenting of a coarctation/re-coarctation of the aorta represents a safe alternative treatment without a significant mid-long-term complication.