Baloon angioplasty with stent implantation in recoarctation of the aorta: an attractive alternative]

The results of transcatheter balloon angioplasty in teenagers and adults with aortic recoarctation are uncertain. Therefore, there is a current trend to prefer a more complex procedure including the implantation of a stent. This study deals with 8 patients aged 7 to 25.3 years (median: 15 years), weighing 20 to 68 kg. (median: 57) and having undergone resection of an aortic coarctation during infancy (24 days to 4 years). All had their lower limb pulses diminished or abolished, elevated blood pressure at rest (and at exercise in the 5 tested patients), and left ventricular hypertrophy. MRI documented the lesion and helped to select seven patients whose stenosis was short and remote enough from the origin of the main aortic collateral. In one case, the decision to stent was taken as an emergent measure to treat an aortic dissection which appeared shortly after balloon dilatation. The effectiveness of the procedure was immediate in all patients with a 50% increase in diameter of the dilated area, total relief of the gradient, drop to normal values of the blood pressure. These good results persisted at follow-up (3-24 months) in 6 patients, with moderate hypertensive rebounds in the last 2. There were 2 technical problems (premature burst of the balloon, asymmetrical inflation of the stent like an "Eiffel Tower") that could finally be overcome and should no longer occur with the new specially designed so-called "BIB" balloons. Would long term follow-up confirm these early results, one should conclude that this method offers an attractive, safe and effective option to surgery for adolescents and adults with late recoarctation of the aorta.     

Treatment of recoarctation: balloon dilation angioplasty

Balloon dilation of recoarctation of the aorta was performed 47 times in 44 patients 49 +/- 54 months after surgical repair. The initial operation was performed in the neonatal period in 29 patients (66%). The age at balloon dilation was 4.9 +/- 5.3 years (range 2 months to 20 years) and weight was 18 +/- 15 kg (range 2 to 72). Systolic pressure difference across the recoarctation site decreased from 37 +/- 16 to 14 +/- 11 mm Hg and coarctation/aortic diameter ratio increased from 0.45 +/- 0.14 to 0.85 +/- 0.16 immediately after balloon dilation regardless of the nature of the previous operation (subclavian flap [n = 12], resection with end to end anastomosis [n = 21], patch angioplasty [n = 4] or multiple operations [n = 5]). In the ascending aorta, systolic pressure decreased from 120 +/- 25 to 113 +/- 20 mm Hg. In the descending aorta, systolic pressure increased from 85 +/- 15 to 100 +/- 19 mm Hg and pulse pressure increased from 22 +/- 7 to 36 +/- 8 mm Hg. At repeat cardiac catheterization in 21 patients (48%) 12 +/- 8 months after balloon dilation, there was further reduction in systolic pressure difference from 17 +/- 11 to 12 +/- 9 mm Hg with no further change in coarctation/aortic diameter ratio. Aneurysm formation was evident in one patient (2%) immediately after balloon dilation; the aneurysm was unchanged at repeat study 15 months later. A "new" aneurysm was apparent in 2 (10%) of the other 20 patients restudied to date. The occurrence of aneurysm in these three patients was unrelated to balloon size. There were no procedure-related deaths. Three patients (7%) had femoral artery occlusion. Balloon dilation affords good relief of obstruction without adverse sequelae from aortic wall disruption at medium-term follow-up.     

Stent implantation in recoarctation of aorta in infant

We present the case of a 12 month-old infant with critical coarctaion of aorta, arch hypoplasia, atrial and ventricular septal defects who underwent interventional treatment with stent implantation due to recoarctation of aorta. In neonatal period the patient went through complete surgical correction. At the age of four months balloon angioplasty of recurrent coractation was conducted. Eight months later the patient was hospitalised with heart failure (HF) symptoms. Clinical and echographic examination confirmed critical stenosis of aortic isthmus. We performed heart catheterisation with stent implantation to transverse and descending arch with immediate reduction of gradient from 45 mm Hg to 0 mm Hg, widening of the isthmus from 2 to 8 mm and gradual regression of HF symptoms. At 3 years of observation the patient has not presented with any signs of recurrence of the stenosis. The child remains free of HF symptoms with arterial hypertension controlled with pharmacotherapy and with good left ventricular function on echocardiographic examination.     

Age-related aspects of balloon angioplasty for postsurgical aortic recoarctation

Balloon angioplasty is now the elective technique for relief of aortic recoarctation, since it has low mortality, low morbidity, and good results at follow-up. Some concern exists concerning the possible increased risk in young children. To investigate such age-related aspects, we examined 58 children undergoing consecutive balloon angioplasty for postsurgical recoarctation. Of the children, 30 were younger and 28 older than 1 year. Recoarctation was more frequent with ventricular septal defect or other cardiac anomalies (p < 0.001). Systolic hypertension was present in 70% of children aged less than 1 year, but in only 32% of those older than 1 year (p < 0.001). The initial gradient was inversely related with the age at dilation (r = -0.28, p < 0.05), and correlated with systolic blood pressure (r = 0.81, p < 0.01). The procedure was successful in 87% of children older than, and 86% of those under 1 year. Age was not related with residual gradient, nor with the percentage increase of diameter of the site of stenosis. After balloon angioplasty, systolic hypertension was still present in 37% of children younger than 1 year, and in 25% of those older than 1 year (p < 0.05). Three complications occurred in children younger than 1 year, and 6 in those older (p < 0.05). Our results show, first, that recoarctation occurs earlier in the setting of complex disease, second that children suffering recoarctation at a younger age are more likely to be hypertensive, either before or after balloon angioplasty, third, that balloon angioplasty has the same rate of success in children below or above the age of one year, although the procedure still carries a not negligible risk. Finally, the procedure does not carry a higher risk for those children below the age of 1 year.     

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 of postsurgical recoarctation in infants: the risk of restenosis and long-term follow-up

OBJECTIVES: This study was undertaken to evaluate the long-term results of balloon angioplasty (BA) for postsurgical recoarctation in infants. BACKGROUND: Balloon angioplasty is a well-accepted modality for the treatment of recoarctation. However, infants remain a group of concern because of their size, risk for complications and the potential for restenosis with growth. Age <12 months has been determined to be a risk factor for the development of recoarctation after angioplasty for native coarctation. Although studies on postsurgical coarctation have found no relationship between age at angioplasty and the development of recoarctation, few studies specifically addressing infants have been performed. METHODS: Clinical, echocardiographic, hemodynamic and angiographic data on 22 consecutive children <1 year of age who underwent BA between 1986 and 1996 were reviewed. RESULTS: A successful result, defined as a postprocedure gradient of < or =20 mm Hg, was achieved in 20 of 22 (91%) infants with a reduction in the systolic peak pressure gradient from 48 +/- 27 to 9 +/- 10 mm Hg (p < 0.001) and an increase in coarctation diameter from 2.7 +/- 1.1 to 5.2 +/- 1.5 mm (p < 0.001). At long-term follow-up of a median of 56 months (0.6 to 12 years), the restenosis rate after an initial optimal result was 16% (3 of 19). Five (24%) infants required reintervention (2 initially unsuccessful; 3 recoarctation), with a success rate of 95% after two procedures. Suboptimal long-term outcome correlated with a lower infant weight. CONCLUSIONS: Balloon angioplasty can be safely performed in infants, with good long-term results. The risk of restenosis is low and can be successfully managed with repeat angioplasty.     

Co-existence of severe aortic valve stenosis and recoarctation of the aorta treated surgically in childhood

Coarctation of the aorta is treated surgically in most of patients during childhood. However, some of them experience recoarctation in future. A 57 year-old woman suffering from chest pain and decreased activity tolerance was admitted to the cardiac department. Physical examinations, lab tests and cardiovascular imaging revealed severe aortic valve stenosis and insignificant narrowing of the aorta. The patient underwent a surgical replacement of the aortic valve without recoarctation repair.     

Estimation of Doppler gradients at rest and during exercise in patients with recoarctation of the aorta

In patients with suspected recoarctation of the aorta the estimation of the pressure difference between the arms and legs is an important part of the examination. Because this difference is often augmented when the circulation is stressed by exercise, exercise tests are a useful part of the evaluation. Doppler echocardiography was used to estimate this pressure difference in 16 adult patients in whom simultaneous pressure and Doppler recordings were made both at rest and during exercise. There was a close correlation between the invasive peak instantaneous gradient and the Doppler gradient both at rest and during exercise. There was only a moderate correlation between the invasive peak to peak gradient and the Doppler gradient at rest and during exercise. Doppler echocardiography is recommended as an easy and accurate method of estimating the peak instantaneous gradient both at rest and during exercise in patients with suspected recoarctation.     

Balloon dilation angioplasty for coarctation of the aorta

Eleven patients with coarctation of the aorta (C of A) underwent balloon dilation angioplasty at the University of Arizona from November 1983 to January 1985. Eight had previously undergone surgery and 3 had native C of A. Two operations were considered unsuccessful: 1 in a patient who underwent tube graft-descending aortic anastomosis narrowing and 1 in a patient with a native wedge type of C of A. Overall mean gradient fell from 47 to 13 mm Hg immediately after the procedure. Mean gradient at repeat catheterization in 7 patients (mean 8 months after angioplasty) was 6 mm Hg. Five patients showed a transient increase in the gradient measured on the day after angioplasty, with 3 showing a fairly marked increase. Values returned to levels equal to or less than gradients measured immediately after the procedure. Angiographic findings at follow-up catheterization in 7 patients showed no evidence of aneurysm formation in either the operative group or in the 2 patients with native C of A who had a membrane type of deformity. Mean C of A to ascending aortic diameter ratios increased from 0.44 to 0.80. At repeat angiography, the mean ratio was 0.76 in the 7 patients studied.Further longitudinal studies in these patients are necessary before reaching conclusions about the advantage of this procedure over surgery, but these early longitudinal results are encouraging for the populations studied: postoperative patients and patients with native membrane types of C of A.     

Balloon angioplasty for native coarctation of the aorta

Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed.     

Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry

Balloon angioplasty was performed in 200 patients with recoarctation of the aorta in a multicenter prospective study. The average age at the time of the procedure was 7.0 years (range 1 month to 26 years). Systolic pressure (mean +/- standard deviation) in the ascending aorta decreased from 134.5 +/- 23.4 to 127.4 +/- 22.0 mm Hg. The descending aortic systolic pressure rose from 92.7 +/- 18.2 to 114.1 +/- 21.6 mm Hg. Peak systolic pressure differences decreased from 41.9 +/- 19.6 to 13.3 +/- 12.1 mm Hg. The diameter of the recurrent coarctation site increased from 5.2 +/- 2.9 to 8.9 +/- 3.4 mm. After angioplasty residual pressure differences of less than or equal to 20 mm Hg were found in 79.4% of the patients. Five patients died of complications related to the procedure (2.5%). Two deaths were directly related to the technical aspects of the procedure and 3 patients died because of the severity of the underlying disease. One additional patient had a cerebrovascular accident. Femoral artery complications occurred in 17 patients (8.5%) and 8 patients required surgical thrombectomy. Balloon angioplasty offers a satisfactory alternative to surgery for recurrent coarctation; both results and complications compare favorably with surgical therapy.     

Estimation of Doppler gradients at rest and during exercise in patients with recoarctation of the aorta.

In patients with suspected recoarctation of the aorta the estimation of the pressure difference between the arms and legs is an important part of the examination. Because this difference is often augmented when the circulation is stressed by exercise, exercise tests are a useful part of the evaluation. Doppler echocardiography was used to estimate this pressure difference in 16 adult patients in whom simultaneous pressure and Doppler recordings were made both at rest and during exercise. There was a close correlation between the invasive peak instantaneous gradient and the Doppler gradient both at rest and during exercise. There was only a moderate correlation between the invasive peak to peak gradient and the Doppler gradient at rest and during exercise. Doppler echocardiography is recommended as an easy and accurate method of estimating the peak instantaneous gradient both at rest and during exercise in patients with suspected recoarctation.     

Percutaneous transluminal angioplasty of congenital coarctation of the aorta

Two cases of successful dilatation of congenital coarctation of the aorta using the Grüntzig technique are reported. In a 3-week-old boy and an 11-month-old girl, systolic gradients across the narrowed areas were lowered from 50 to 8 mm Hg and from 23 to 8 mm Hg. Although the femoral pulses later disappeared in the younger patient, surgery was avoided. The second patient's gradient has remained minimal for 8 months and no surgery has been performed.     

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)