Complete resolution of systemic venous baffle obstruction and baffle leak using the gore excluder® covered stent in two patients with transposition of the great arteries and prior mustard procedure

We present two patients with a history of Mustard repair of transposition of the great arteries. Both patients presented with exertional limitation and demonstrated superior systemic venous baffle obstruction as well as multiple baffle leaks. In both patients stent relief of obstruction and baffle leak exclusion was accomplished using a combination of bare metal stents and the aortic extension portion of the Gore Excluder® covered stent (W.L. Gore and Associates, Flagstaff, Arizona). © 2010 Wiley‐Liss, Inc.     

Failing left ventricle to ascending aorta conduit—Hybrid implantation of a melody valve and NuMed covered stent

We present the case of a 36‐year‐old woman with increasing shortness of breath, a new 3/4 diastolic murmur, and a complex history of LV outflow tract obstruction. She has undergone multiple surgeries including the replacement of her old LV apex to ascending aorta conduit with a 20‐mm Gore‐Tex tube graft, addition of a 24‐mm homograft sutured between the conduit and the LV apex, and insertion of a 21‐mm Freestyle porcine valve conduit between the Gore‐Tex tube graft and allograft at age 23. The current assessment showed a failing Freestyle conduit prosthesis leading to left heart decompensation. Due to substantial surgical risk, the patient underwent successful implantation of a Melody valve into the Gore‐Tex tube and exclusion of the failing Freestyle bioprosthesis with a NuMed CP stent in a hybrid procedure. The case nicely illustrates the collaborative potential of cardiovascular surgeons and interventional cardiologists in the new arena of a hybrid operating room. Complex hybrid procedures like the current one, especially those including percutaneous placements of valves, offer therapeutic options for patients that are otherwise too high risk for conventional open heart surgery. © 2013 Wiley Periodicals, Inc.     

Treatment of focal distal abdominal aortic stenosis with the GORE VIABAHN VBX balloon expandable covered stent

The incidence of focal infrarenal stenosis of the aorta is rare. Endovascular therapy has evolved as a first‐line treatment of aortoiliac occlusive disease and has been shown to substantially improve health‐related quality of life. The 8 French sheath compatible, GORE VIABAHN VBX (GORE Flagstaff, AZ) balloon expandable covered stent offers the traditional benefits of a balloon expandable covered stent with a design that improves on flexibility. We report three cases with the use of this system for treatment of infrarenal stenosis of the aorta.     

Coarctation of the aorta treated with the Advanta V12 large diameter stent: Acute results

Objectives: To report on the early results of treatment of coarctation of the aorta by dilation with a new polytetrafluoroethylene covered stent. Background: Transcatheter dilation of aortic coarctation carries the risk of aneurysm or rupture. Covered stent implantation reduces this risk but requires a large delivery system. The Advanta V12 LD covered stent is premounted and requires a 9–11 Fr delivery system. Methods: Covered stents on balloons of a diameter sufficient to anchor the stent in the coarctation were implanted using the smallest available delivery system. Secondary dilation with larger diameter balloons was performed until the pressure gradient was <20 mm Hg and the stent was opposed to the aortic wall. Results: Twenty‐five patients with aortic coarctation underwent stent implantation. Coarctation diameter increased from (6.3 ± 3.5) mm to (14.4 ± 2.3) mm (P < 0.0001). Peak pressure gradient decreased from (25.3 ± 11.6) mm Hg to (2.5 ± 3.0) mm Hg (P < 0.0001). The stent achieved the desired diameter in all cases. There were no complications. At short‐term median follow‐up of 4.9 months, all patients are alive and well with no evidence of recoarctation or aneurysm. Conclusions: These initial results show that the covered Advanta V12LD stent is safe and effective in the immediate treatment of coarctation of the aorta through a low profile delivery system of 8–11 Fr. Long term follow up is required. © 2009 Wiley‐Liss, Inc.     

Transcatheter creation of bidirectional cavopulmonary connections by needle punctures in two patients

We report on two patients who received a transcatheter cavopulmonary connection by a needle puncture under deep conscious sedation. In both patients, the vessel‐to‐vessel connection was achieved by a venous access into the superior caval vein and direct needle puncture of the pulmonary artery. The two cavopulmonary anastomoses were held open by a covered stent and a bare‐metal stent, respectively.     

First human implant of the Alterra Adaptive PrestentTM: A new self‐expanding device designed to remodel the right ventricular outflow tract

Current balloon expandable transcatheter valves have limited applicability to patients with “native” right ventricular outflow tracts (RVOT), meaning those who have had previous surgery and are left with large, compliant, irregular RVOT. The Alterra Adaptive Prestent^TM is a self‐expanding, partially covered stent that was designed to internally reconfigure these types of RVOT, making them suitable for implantation of a commercially available balloon expandable heart valve, the SAPIEN 3. Herein, we describe the first human implant of this device.     

Treatment of aortic isthmus atresia with a covered stent

We report on successful treatment of an elderly patient with congenital aortic isthmus atresia with a covered stent. © 2008 Wiley‐Liss, Inc.     

Transcatheter redirection of hepatic venous blood to treat unilateral pulmonary arteriovenous malformations in a Fontan circulation by short‐term total exclusion of the unaffected lung

Clinically significant unilateral pulmonary arteriovenous malformations (PAVM) can develop in patients with a Fontan circulation when there is unbalanced distribution of hepatic venous (HV) blood flow to the lungs. There are reported surgical and transcatheter techniques to treat PAVMs by rerouting HV return, with promising short‐term results. We report a case of a novel, technically simple transcatheter approach to redirect HV blood flow in an adult Fontan patient with polysplenia syndrome and severe unilateral PAVMs. Our patient had a two‐stage procedure, the first to redirect all HV blood flow to the affected lung with a single covered stent, and a second to confirm resolution of PAVMs and to reintroduce HV effluent to the unaffected lung. At 10‐month follow‐up, her oxygen saturations had increased from 75% to 93% with a marked improvement in her functional status.     

Percutaneous stent implantation into coronary arteries in infants

Objectives: To investigate the feasibility, procedural techniques, safety, and overall potential of percutaneous coronary angioplasty and stent implantation in infants with coronary artery disease and acute coronary syndrome. Background: Despite extensive experience in adult patients, percutaneous coronary intervention remains uncommon in children and extremely rare in infants. Methods: Retrospective review including all children who underwent percutaneous coronary angioplasty in Rady Children's Hospital—San Diego during a period of 4 years. Results: Seven children including four children less than 15 months of age underwent percutaneous coronary intervention with coronary stent implantation in the proximal portion of the left or right coronary arteries. Successful stent placement with excellent revascularization was achieved in all cases. Mean coronary artery diameter was 0.65 mm prior to stent placement. Balloon angioplasty resulted in suboptimal resolution of coronary stenosis, thus bare metal stents were implanted in all cases, dilated to a mean of 2.5‐mm internal diameter. Average intervention‐free period was 434 days after stent implantation. In‐stent re‐stenosis and stent thrombosis did not occur if the implanted stent diameter was greater than 2.5 mm and the patient received dual anti‐platelet therapy. Conclusions: Our experience suggests that coronary artery stent implantation is a feasible and relatively safe palliative option in infants and toddlers with coronary stenosis. It is a viable strategy for bridging patients with acute ischemia or poor ventricular function to elective surgical revascularization or transplantation. © 2011 Wiley Periodicals, Inc.     

Stenting of stenotic or occluded iliofemoral veins,superior and inferior vena cavae in children with congenital heart disease: Acute results and intermediate follow up

Objectives:

To determine the short and intermediate term outcome following systemic venous stent placement in children with congenital heart disease.

Background:

Patients with congenital heart disease are at risk of stenosis or occlusion of systemic veins following indwelling lines or catheterizations. Stent dilation may ameliorate symptoms and open the vessel for use during future procedures. We report our acute and intermediate results.

Methods:

All patients with systemic venous stent placement in the iliofemoral veins, inferior or superior vena cava at our institution between 1998 and 2006 were included. Initial and the follow‐up catheterization data were reviewed retrospectively.

Results:

70 stents were placed in 33 patients (36 vessels). Median age was 2.6 years (0.2–14.2) and weight 11.5 kg (3.8–78.7). 17/36 vessels (47%) were occluded requiring recanalization. Following stent delivery, the mean minimum vessel diameter increased from 3.1 ± 3.2 to 7.2 ± 3.0 mm (P < 0.001). There were no major complications. Seventeen patients and vessels had a total of 62 follow‐up catheterizations, with median length of follow‐up 4.1 years (0.7–9.3). During intermediate follow up, 7/17 vessels (41%) required additional intervention. Six patients had additional balloon dilation of existing stents, and one additional stent was placed. Vessels were further dilated to 8.4 ± 3.5 mm at the last catheterization.

Conclusion:

Systemic venous stents are safe and effective in recanalizing stenosed or occluded vessels. At follow‐up, reocclusion can occur, however, previously placed stents can be safely recanalized if necessary. Future studies will determine if stenting is indicated in a broader population. © 2009 Wiley‐Liss, Inc.     

Endovascular stents for treatment of coarctation of the aorta: Acute results and follow‐up experience

Balloon angioplasty as treatment for coarctation of the aorta is increasingly performed. Endovascular stents have been proposed as a means of improving the efficacy and safety of the procedure. In this report, we describe one institution's immediate results and clinical follow‐up after implantation of endovascular stents. Retrospective analysis for endovascular stent placement for coarctation of the aorta between 1993 and 2002 was made. The immediate hemodynamic results and clinical follow‐up were reviewed. Thirty‐two patients underwent attempted stent placement for coarctation. Twenty‐three patients had postoperative recurrent coarctation and nine had native coarctation. The systolic gradient decreased from 31 to 1.8 mm Hg (P = 0.001) and the diameter was increased 8.1 to 13.5 mm (P–0.001). Mean follow‐up was 1.5 years. The mean follow‐up gradient as assessed by sphygomomanometry was 13.1 mm Hg. Eight patients underwent 10 successful further dilations. Complications included one stent migration and one aortic dissection. The use of stents as an adjunct to balloon angioplasty in selected patients with coarctation can be performed with low complication rates and provides excellent immediate relief of obstruction with promising follow‐up. Further dilation of these stents is possible. Long‐term follow‐up is warranted. Catheter Cardiovasc Interv 2004;62:499–505. © 2004 Wiley‐Liss, Inc.     

Novel approach to percutaneous stent implantation for coarctation of the aorta: the railway technique.

Percutaneous stent implantation is a widely accepted therapeutic procedure for recurrent coarctation of the aorta. Distal stent migration during deployment is not uncommon and can result in vascular dissection. The following report describes the creation of an arterial railway in two patients with coarctation. The railway allowed for stent placement with minimal movement of the balloon/stent assembly during deployment. This strategy may decrease the risk of stent malposition and could be particularly useful in cases where anatomy is difficult.     

Bailout stenting for critical coarctation in premature/critical/complex/early recoarcted neonates

Background: Surgical repair of critical coarctation can be problematic in premature, critical, complex, or early postoperative neonates. Objectives: We aimed to review our experience with stent implantation to defer urgent surgery to an elective time. Methods: Fifteen neonates with severe aortic coarctation: five premature‐hypotrophic (1,400–2,000 g), six critical and complex cardiac malformation, four early (1 day [0–2 days]; median [range]) after surgical coarctectomy or complex arch reconstruction. Bare coronary stents (diameter 4.0 [3.5–5.0] mm; length 10 [8–16] mm) were used. Stents were removed surgically depending on clinical needs. Results: Adequate aortic flow was obtained in 15 patients. The femoral artery was preserved in 13/15 patients. Two deaths occurred before stent removal and were nonprocedure related. In patients with simple stented coarctation, the stent was removed after 2.8 [0.2–5.0] months. In complex cardiac malformation, stents were finally removed 3.0 [0.2–78] months after implantation. Surgical technique: simple coarctectomy end‐to‐end in eight, extensive arch patch reconstruction in four. One patient is awaiting stent removal. The final maximum systolic velocity (cw‐Doppler) across the aortic arch was 1.7 [1.2–2.5] m/sec. Conclusions: In premature/critical/complex neonates with severe coarctation, bailout stenting followed by early or late surgical coarctectomy appears a promising concept. © 2009 Wiley‐Liss, Inc.     

Stenting of coarctation of the aorta.

The purpose of the present study was to assess the usefulness of balloon expandable Palmaz intravascular stents in the transcatheter treatment of children and young adults with native and recurrent coarctation of the aorta, and to develop an improved intravascular stent and balloon delivery catheter specifically developed for vascular obstructions associated with congenital heart disease, including coarctation of the aorta. Twenty-one patients, 8 native and 13 recurrent coarctations, were successfully treated with the Palmaz stent. However, limitations and disadvantages in stent design and the single balloon delivery system were uncovered. Therefore, the NuMED CP stent and BIB delivery catheter were developed and used to treat 25 patients with native (17) and recurrent (8) coarctation successfully. Improvements in stent design and long-term follow-up using three-dimensional spiral CT scan will be helpful in determining the role of transcatheter stent therapy for native and recurrent coarctation of the aorta. Cathet Cardiovasc Intervent 2001;54:112-125.     

A premounted stent that can be implanted in infants and re‐dilated to 20 mm: Introducing the Edwards Valeo Lifestent

Intravascular stenting (IS) for vascular stenoses in congenital heart disease provides superior gradient relief and angiographic results over balloon angioplasty (BA) alone. The advantages of IS, however, are difficult to apply to infants, toddlers, and small children due to technical challenges in placing large, long sheaths and the risk of creating future stenoses in stents that cannot be re‐dilated to keep pace with somatic growth. This report highlights the Edwards premounted re‐dilatable biliary stent, which was safely placed in four infants and small children with excellent hemodynamic and angiographic results. Bench testing revealed the stent has adequate radial strength and can be re‐dilated to a maximal diameter of 20 mm. © 2009 Wiley‐Liss, Inc.     

Pulmonary artery stents: Long‐term follow‐up

Objectives: Determine the long‐term outcomes of branch pulmonary artery (PA) stents. Background: PA stents in congenital heart disease effectively relieve stenoses in the short‐term. Published long‐term data are limited. Methods : Patients enrolled in an FDA IDE protocol from 1989–92 were included. Clinical follow‐up and catheterization data were evaluated. Patients were included if >5 year follow‐up data was available or if mortality occurred following the initial procedure. Results : There were five deaths: four due to progression of their underlying heart disease, and one from a complication during a follow‐up catheterization. Clinical data for 43 surviving patients demonstrated 39 patients (91%) are in NYHA class I or II. Seven patients underwent surgical intervention during the follow‐up period (five RV‐PA conduit, two Fontan revisions), but none addressed PA stenosis. Final repeat catheterizations were performed in 36 patients (55 stents) 7.2 ± 4.3 years post stent insertion with 1.2 ± 0.9 further procedures with stent dilations. In this subgroup, the minimum vessel diameter increased from 4.7 ± 1.8 to 13.4 ± 2.4 mm (P < 0.001), and the pressure gradient improved from 41 ± 25 to 9 ± 11 mm Hg (P < 0.001). Higher initial gradient and smaller balloons were associated with a final stent diameter of <14 mm (P = 0.030 and 0.046). Jailed vessels occurred in 49% of stents with abnormal angiographic flow in 18/55. Six repeat catheterizations resulted in complications, including the one procedural death. Conclusion : Stents implants for PA stenoses provide effective improvement in vessel caliber in the long‐term. Although repeat interventions are necessary, this procedure reduces RV pressure and provides an important alternative to surgery for residual PA obstruction. © 2009 Wiley‐Liss, Inc.     

“Over‐and‐under” pericardial covered stent with paclitaxel balloon in a saphenous vein graft

Treatment of vein graft disease remains a challenge in interventional cardiology because of the risk of embolization and no‐reflow phenomenon. Currently available distal protection devices have their limitations. The PTFE‐covered stents may be well suited for venous graft lesion treatment, but those available commercially to date have poor crossing profiles, and deliverability and high rates of restenosis. We report the first use of over‐and‐under pericardium‐covered stent in combination with drug‐eluting balloon to treat venous graft disease. © 2009 Wiley‐Liss, Inc.     

Stent graft exclusion of a pseudoaneurysm in a Blalock‐Taussig shunt

This case is the first report of slow‐growing pseudoaneurysm after vessel dissection secondary to two stents implantation into classic Blalock Taussig shunt in a patient with pulmonary atresia and ventricular septal defect. Pseudoaneurysm was successfully excluded by a percutaneous approach with self‐expandable stent graft deployment from the aorta to the middle of the Blalock Taussig shunt. Nearly 3 years after the procedure, the classic BT is patent, and there were no restenosis or thrombosis in spite of the very long length of the stented segment. © 2010 Wiley‐Liss, Inc.     

Ductal stent endocarditis resulting in a large aortic pseudoaneurysm

An infant with ductal dependent pulmonary blood flow who underwent neonatal ductal stenting and, 4 months later, developed ductal stent endocarditis due to Streptococcus gallolyticus subsp. pasteurianus was described. The infection was associated with a moderate aortic pseudoaneurysm and the patient was treated with antibiotics as well as surgical aortic pseudoaneurysm repair. This novel and unusual complication of ductal stent placement warrants reporting.     

Transhepatic implant of a trimmed Melody™ valved stent in tricuspid position in a 1‐year‐old infant

Percutaneous valved stent implantation is precluded in small infants because large delivery sheaths and large devices. We describe a procedure in a 1‐year‐old boy in whom a 19 mm Epic? valve in tricuspid position had become dysfunctional. As the internal diameter of the prosthetic valve was about 16 mm, the only available valve was the Melody? valved stent. Technical modifications were required to address issues like venous access, the bulky delivery system, and the length of the valved stent. The Melody? valved stent was surgically trimmed and mounted on a 16 mm Tyshak balloon, access was provided transhepatically through a short 18 Fr sheath. After deployment, the intrahepatic route was sealed with two vascular plugs (8 and 10 mm) in tandem. The procedure was uncomplicated with perfect valve function 18 months after implant. © 2016 Wiley Periodicals, Inc.