Aortic Pseudo Aneurysm Complicating Coarctation Stenting Successfully Treated with a PTFE Balloon Expandable Covered Stent

Percutaneous stenting of both native and recurrent coarctation of the aorta has become an acceptable alternative to surgical repair in most centers throughout the world. Severe complications such as aortic rupture, dissection, and late pseudo aneurysm formation are rare but worrisome complications. In many countries, commercially available balloon expandable covered stents designed for intravascular use are used either for primary stenting, or in treating complications once identified. These endovascular stents, however, are not available in the United States. We report the use of a commercially available covered stent, which has been approved by the Food and Drug Administration for tracheal use, to exclude an aortic pseudo aneurysm that was identified late after stenting a native coarctation.     

Emergency stent graft deployment for acute aortic rupture following primary stenting for aortic coarctation.

We present a case of endovascular stenting for aortic recoarctation complicated by acute aortic rupture, which was successfully treated by emergency stent graft deployment. This case illustrates the potential serious complication that can occur during aortic stent dilatation and how the prompt deployment of a stent graft helped to change the clinical outcome of this life-threatening situation.     

Endovascular coil embolization of a complex aortic arch pseudoaneurysm following arch stenting

Pseudoaneurysm formation is a life‐threatening complication of thoracic aortic stenting due to the high risk of rupture. When located in the aortic arch, anatomic features may pose difficulties in choosing the optimal treatment strategy. Here, we describe the first poststenting aortic arch pseudoaneurysm treated by endovascular coil embolization. This approach, which we performed in a multidisciplinary setting, may be a feasible alternative in patients not considered suitable for open repair or stent‐grafting. As an acute pseudoaneurysm may develop and rapidly expand during the first days after aortic stenting, early follow‐up imaging is preferable.     

Usefulness of stenting in aortic coarctation in patients with the Turner syndrome

We report our experience with stent implantation for treatment of aortic coarctation in patients with Turner syndrome. Ten consecutive patients with Turner syndrome and aortic coarctation (median age 12 years, range 9 to 24) underwent coarctation stenting. Of these, 6 patients were treated for isolated coarctation and 4 for recurrent coarctation (3 after balloon dilation and 1 after balloon dilation and surgical repair). Bare metal stents were implanted in 7 patients and covered stents in 3. Immediately after stent implantation, peak systolic gradient decreased from 46.1 ± 24.3 to 1.9 ± 2.1 mm Hg (p <0.001). Aortic diameter at coarctation site increased from 5.1 ± 3.2 to 15.3 ± 2.0 mm after stenting (p <0.001). There were no deaths or procedure-related complications. During a median follow-up of 30.5 months, no patient developed restenosis. Two patients developed late aortic aneurysms at the coarctation site. In conclusion, stent implantation for aortic coarctation in patients with Turner syndrome appears to be a safe and effective alternative to surgical repair. Larger cohorts and longer-term follow-up are required to determine the effects of the procedure on the aortic wall.     

In-stent restenosis and aneurysm development after bare stent implantation: rescue by e-PTFE-covered cheatham- platinum stent

We report on three cases of primary endovascular bare stenting for native aortic coarctation complicated by aortic aneurysm or in-stent stenosis because of neointimal proliferation that were successfully treated by covered stent. These cases show how the deployment of a covered stent may be a safe and definitive therapeutical option in the management of these complications.     

Different transcatheter strategies for aortic coarctation associated with patent ductus arteriosus

BackgroundOlder patients with combination of aortic coarctation and large patent ductus arteriosus can be managed with transcatheter interventions. The strategies depend on anatomy of coarctation and size of ductus arteriosus.MethodsWe present three different patients with this combination. The anatomic factors like isthmic hypoplasia, dilatation of post coarctation descending aorta and size of ductus arteriosus were noted.ResultsPatients with isthmic hypoplasia needed stent angioplasty of the coarctation. If there is no dilatation of post coarctation aorta, a single covered stent excluded the ductus arteriosus and relieved the coarctation gradients. Dilated post coarctation aorta precluded a covered stent and warranted closure of duct with occluder device and stent angioplasty of coarctation. When there is a good sized aortic isthmus in a discrete membranous coarctation, device closure of the duct and balloon aortoplasty was successful.ConclusionsIn coarctation with patent ductus arteriosus associated with good sized aortic isthmus, closure of duct with duct occluder device and balloon aortoplasty would correct the lesions. If there is isthmic hypoplasia, device closure of the duct and stenting of the coarctation is needed. Covered stent is a reasonable alternative only in presence of non dilated descending aorta.     

Stent redilation in canine models of congenital heart disease: Pulmonary artery stenosis and coarctation of the aorta

In a canine puppy model, pulmonary artery stenosis was created by banding the left pulmonary artery to 30–40% of its original diameter. Animals underwent right heart catheterization and angiography 1–2 mo later, and Palmaz P308 stents were implanted. Stent redilation was performed 3–5 mo later. One mo postredilation, the animals were restudied and sacrificed. Coarctations of the aorta were created by transverse aortic incision and longitudinal repair. P308 stent implantation was performed 2–3 mo later. Stent redilation was performed after 6–10 mo, and the animals were restudied and sacrificed 1–2 mo later. Stent implantation was performed in 6 puppies with pulmonary artery stenosis, as 2 animals developed postoperative pulmonary arterial hypoplasia, precluding stenting. The stenosis diameter increased from 4.8 ± 0.5 mm to 7.4 ± 0.6 mm (mean ± SE) following stenting (P = 0.005), and increased further to 9.2 ± 0.7 mm following redilation (P < 0.001). There were no significant vessel tears or ruptures. Coarctation stenting was performed in 8 animals. The coarctation was dilated from 5.8 ± 0.9 mm to 9.8 ± 0.6 mm (P < 0.001), and to 13.5 ± 0.5 mm at redilation (P = 0.002). Redilation could not be performed in 1 animal. Aortic rupture and death occurred in 2 of 7 animals at redilation. Stent implantation and redilation in experimental pulmonary artery stenosis appears safe and effective. Though stent implantation for coarctation of the aorta appears safe, there was a 28% aortic rupture rate at stent redilation in this model. © 1996 Wiley-Liss, Inc.     

First‐in‐man use of a tapered endovascular stent graft for treatment of aneurysm after coarctation repair

Objectives : Endovascular stenting of aneurysms late after surgical repair of coarctation may have to deal with marked changes in aortic diameter proximal and distal to the aneurysm. We report our first‐in‐man successful use of a custom‐made tapered (variable diameter) covered stent. Methods : The aneurysm was 42 mm in diameter with a length of 40 mm. On MRI, the aorta measured 19.6 mm proximal and 13.3 mm distal to the aneurysm. The aim was to oversize the stent by 10–20%. A covered Cheatham‐platinum stent was designed so that cranial portion of the stent would expand to 22 mm and the caudal portion to 15 mm with a length of 8.5 cm when fully inflated. The stent was mounted on a balloon‐in‐balloon delivery system and was delivered through an 18 F femoral arterial sheath. Rapid‐pacing technique was used for deployment. Results : The stent was successfully deployed without complications. After deployment, the stent diameter measured 21.2 mm cranially and 15.6 mm caudally. A mild distal endoleak due to inadequate fixation of the stent graft was resolved by post dilation expanding the stent diameter to 22.1 mm and 15.9 mm, respectively. The femoral access site was closed using two percutaneous closure devices and the patient discharged the day after the procedure. Follow‐up CT‐angiography showed continued successful exclusion of the aneurysm. Conclusions : A new custom‐made balloon expandable covered stent‐design enabled successful treatment of an aortic aneurysm. This design may offer greater potential for more favorable initial angiographic results and potentially long‐term outcomes due to superior apposition to the aortic wall. © 2010 Wiley‐Liss, Inc.     

Redilation of e‐PTFE covered CP stents

Objectives: To evaluate the possibility to redilate covered Cheatham‐Platinum stents during follow‐up, in particular in growing children with aortic coarctation. Background: There are no data in the literature about the redilation of ePTFE covered CP stents. Methods: Sixty covered CP stents were implanted in patients with aortic coarctation or recoarctation between January 2004 and October 2007. Seven patients (mean age 14.2 ± 3.7 years) needed to repeat the hemodynamic study due to somatic growth and increase of aortic gradient with the occurrence of systemic hypertension. Two had near‐atretic aortic coarctation, three had postsurgical recoarctation and aneurysm formation, one had native aortic coarctation associated with aneurysm of the arterial wall, and one had severe native aortic coarctation. Results: Procedures were performed a mean of 20 ± 5 months (range, 12–24 months) after the primary stent implantation. Fluoroscopy time ranged between 7 and 15 min (median, 10 min) whereas procedure time ranged between 60 and 75 min (median, 65 min). After redilation the gradient across the stenosis decreased from a median value of 35 mm Hg to a median value of 5 mm Hg. The stent diameter increased of 20–50% the predilation value. No complications occurred and angiographic controls showed that the stenoses have been relieved. Follow‐up: During a median follow‐up of 12 months (6–30 months) the results were stable without complications. Conclusion: Covered Cheatham‐Platinum stents can be easily redilated © 2008 Wiley‐Liss, Inc.     

Collapse of the advanta V12 large diameter covered stent following implantation for aortic coarctation

We report a case of collapse of the Advanta V12 Large Diameter (LD) covered stent following previous successful implantation for native aortic coarctation. This unreported complication was successfully managed with subsequent stent redilation and implantation of two covered Cheatham‐Platinum stents within the collapsed Advanta V12 stent. This case highlights the importance of correct stent apposition to the aortic wall and also raises some concerns regarding the radial strength of the Advanta V12 stent. © 2013 Wiley Periodicals, Inc.     

Restenosis after aortic stenting

Aortic coarctation is a recognized arteriopathy in patients with Williams' syndrome. We present an adolescent with Williams' syndrome who developed rapid restenosis after primary stenting of coarctation of the aorta. We believe such restenosis within the stent is due to a proliferative response of the abnormal aortic wall. Attention should be paid to the potential for restenosis during follow-up after stenting of aortic coarctation in patients with Williams' syndrome.     

Successful endovascular management of an aortic rupture following stent placement for severe atherosclerotic stenosis: A case report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome.     

Endovascular aortic coarctation stenting in adolescents and adults: angiographic and hemodynamic outcomes.

OBJECTIVES: To assess the procedural, clinical, angiographic, and hemodynamic outcomes, including ambulatory blood pressure monitoring at 1 year in adolescent and adult patients undergoing primary stenting for treatment of aortic coarctation. BACKGROUND: Stenting is widely used for treatment of aortic coarctation. Data regarding efficacy of this treatment for control of hypertension at 1 year is scant, with only one reported series of planned angiographic follow up. The impact of newer type stents for this procedure is also unknown. METHODS: Thirty-seven patients undergoing stenting for aortic coarctation, over a 3-year period in a tertiary centre were studied as part of an observational protocol. RESULTS: Peak gradient across the coarctation fell from 28.3 +/- 15.1 to 3.7 +/- 4.1 post procedure and was 11.9 +/- 8.9 mmHg (P < 0.05 compared to baseline) at 1 year. There was one major complication (2.7%), with no deaths. Small aneurysms were seen in three patients (13%) on follow up angiography at 1 year. Right arm systolic blood pressures fell from 155 +/- 19 to 132 +/- 22 (P < 0.05) at 6 weeks and was 132 +/- 16 mmHg (P < 0.05 compared to baseline) at 1 year. Ambulatory average systolic blood pressures fell from 142 +/- 14 to 133 +/- 15 at 6 weeks (P < 0.05) and to 125 +/- 12 mmHg (P < 0.05 compared to baseline) at 1 year. No significant differences were seen in procedural outcomes between patients receiving Palmaz and CPNumed stents. CONCLUSION: Primary stenting of aortic coarctation in adolescents and adults results in excellent clinical and angiographic outcomes and sustained hemodynamic benefits at 1 year as evidenced by significant reduction in systolic blood pressure and gradients. Close follow up is required to monitor aneurysm formation.     

Initial and six-year results of stent implantation for aortic coarctation in children

Although stenting has been used as a treatment option for aortic coarctation (CoA) at increasingly younger ages, limited information is available on the long-term follow-up of stent implantation for CoA in pediatric patients. A total of 74 patients with CoA (mean age 8 ± 3 years) underwent stent implantation; 42 were treated for isolated native CoA and 32 for recurrent CoA. A total of 87 stents were implanted (bare metal stents in 71 patients and covered stents in 3 patients). Redilation of a previously implanted stent was performed in 32 patients. Immediately after stenting, the peak systolic pressure gradient decreased from 68 ± 16 mm Hg to 8 ± 5 mm Hg (p <0.05), and the CoA diameter increased from 5 ± 3 mm to 16 ± 3 mm (p <0.05). The most important procedural complication was aneurysm formation in 1 patient that was successfully treated with implantation of a covered stent. No early or late deaths occurred and no evidence was found of late aneurysm formation during a follow-up period of 6 years. Late stent fracture was observed in 3 patients. At the end of follow-up, no cases of recoarctation were identified on multislice computed tomography or magnetic resonance imaging, and 67 (85%) of the 74 patients were normotensive, receiving no medications. In conclusion, stent implantation is an effective and safe treatment alternative to conventional surgical management for the treatment of CoA in selected pediatric patients.     

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.     

Optimizing imaging after coarctation stenting: the clinical utility of multidetector computer tomography.

Following stenting for coarctation of the aorta, it can be difficult to image the stent adequately using cross-sectional echocardiography. Unless there is marked clinical concern regarding stent patency, repeat cardiac catheterization is not warranted. Multidetector computed tomography (MDCT) is a useful alternative imaging modality. We report a case that highlights the clinical utility of MDCT for imaging patients who have had stenting of aortic coarctation. MDCT clearly revealed stent fracture as the cause of late stent failure and recoarctation.     

Stent implantation for aortic coarctation complicating the Norwood operation in a 48-day-old baby.

A female infant developed severe aortic coarctation 42 days after a Norwood operation. Balloon dilatation was ineffective due to rapid recoil of the narrowing, but stent implantation completely abolished coarctation. Although the patient died because of low systemic output with high pulmonary flow 62 days after stent implantation, an autopsy showed that the implanted stent was widely patent without any restenosis. Transcatheter stent implantation should be considered for coarctation in selected situations even in early infancy.     

Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: a multi-institutional study.

BACKGROUND: We report a multi-institutional experience with intravascular stenting (IS) for treatment of coarctation of the aorta. METHODS AND RESULTS: Data was collected retrospectively by review of medical records from 17 institutions. The data was broken down to prior to 2002 and after 2002 for further analysis. A total of 565 procedures were performed with a median age of 15 years (mean=18.1 years). Successful reduction in the post stent gradient (<20 mm Hg) or increase in post stent coarctation to descending aorta (DAo) ratio of >0.8 was achieved in 97.9% of procedures. There was significant improvement (P<0.01) in pre versus post stent coarctation dimensions (7.4 mm+/-3.0 mm vs. 14.3+/-3.2 mm), systolic gradient (31.6 mm Hg+/-16.0 mm Hg vs. 2.7 mm Hg+/-4.2 mm Hg) and ratio of the coarctation segment to the DAo (0.43+/-0.17 vs. 0.85+/-0.15). Acute complications were encountered in 81/565 (14.3%) procedures. There were two procedure related deaths. Aortic wall complications included: aneurysm formation (n=6), intimal tears (n=8), and dissections (n=9). The risk of aortic dissection increased significantly in patients over the age of 40 years. Technical complications included stent migration (n=28), and balloon rupture (n=13). Peripheral vascular complications included cerebral vascular accidents (CVA) (n=4), peripheral emboli (n=1), and significant access arterial injury (n=13). Older age was significantly associated with occurrence of CVAs. A significant decrease in the technical complication rate from 16.3% to 6.1% (P<0.001) was observed in procedures performed after January 2002. CONCLUSIONS: Stent placement for coarctation of aorta is an effective treatment option, though it remains a technically challenging procedure. Technical and aortic complications have decreased over the past 3 years due to, in part, improvement in balloon and stent design. Improvement in our ability to assess aortic wall compliance is essential prior to placement of ISs in older patients with coarctation of the aorta.     

Use of covered Cheatham-Platinum stents in aortic coarctation and recoarctation

We inserted covered Cheatham-Platinum stents in 4 patients, ranging in age from 12 to 19 years, who weighed between 45 and 94 kg. All the patients had aortic coarctation, with surgical repair having been attempted previously in one, and with balloon dilation having been performed as the primary treatment in two, resulting in formation of aneurysms. The fourth patient had not received any treatment. The gradients were reduced from 10 to 40 mmHg before insertion of the stent to 0 to 5 mmHg after stenting. No complications were encountered. All the patients are well at an interval of 3 to 14 months after stenting.     

Endovascular approaches for complex forms of recurrent aortic coarctation.

PURPOSE: To review a single-center experience with endovascular treatment of recurrent aortic coarctation in adults. METHODS: Since 1998, 11 patients (9 men; mean age 48+/-15 years, range 16-63) with recurrent aortic coarctation following previous coarctation repair were referred to our institution for treatment. Clinical presentations included pseudoaneurysm (n=2), restenosis (n=3), pseudoaneurysm accompanied by restenosis (n=4), and rupture of a post-coarctation pseudoaneurysm (n=2). All patients were treated using an endovascular approach as part of a single-center investigational device exemption protocol. RESULTS: Endovascular interventions included Palmaz stent implantation (n=3), implantation of an endoluminal graft (n=2), or a combination of both treatments in 6 patients. Three patients underwent balloon angioplasty before stenting or endografting, and 2 patients had a carotid-subclavian bypass done before the endovascular repair. All repairs were technically and clinically successful. The median length of stay after repair was 2.0+/-2.3 days. In follow-up, 2 patients underwent a carotid-subclavian bypass for left upper extremity claudication. Two patients required reintervention owing to migration of the stent in 1 and an endoleak 2 years after the initial procedure in the other. CONCLUSION: Endovascular approaches to adult coarctation appear to be safe and effective. With the emergence of endoluminal grafts and the widespread availability of the Palmaz stent, endovascular repair offers an excellent alternative to open surgery for complex cases of recurrent coarctation. Additional studies are indicated to assess the long-term outcomes of these patients.