Transcatheter double stent implantation for treatment of middle aortic coarctation syndrome

A 13‐year‐old boy presented with severe systemic hypertension. His upper limb blood pressure measured 190/100 mm Hg and lower limb blood pressure measured 98/64 mm Hg. The brachial pulses were bounding and femoral pulses were not palpable. Echocardiography and magnetic resonance angiography confirmed middle aortic syndrome. There was severe diffuse thoraco‐abdominal coarctation with continuous Doppler run‐off. Cardiac catheterization was undertaken and using a retrograde approach two Advanta V12 stents were implanted in the complex thoraco‐abdominal coarctation. The gradient across the coarctation was reduced from 80 to 40 mm Hg gradient with a significant improvement in the luminal diameter of the aorta. His upper limb blood pressure reduced to 142/78 mm Hg six weeks later. © 2013 Wiley Periodicals, Inc.     

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.     

Early and mid‐term results with the growth stent—A possible concept for transcatheter treatment of aortic coarctation from infancy to adulthood by stent implantation?

Aims : Evaluation of the Growth Stent—a stent consisting of two stent halves connected by reabsorbable sutures—for the treatment of aortic coarctation in infants. Methods and Results : Surveillance study of 13 Growth Stents implanted in 12 patients aged 1–15 months (median 5 months). Body weight ranged from 3.4–12.8 kg (median 5.4 kg). Eight patients suffered from aortic (re‐)coarctation, four of them from stenosis of the aortic anastomosis after a Norwood I procedure. The follow‐up period was 24 months (11–51 months). Pressure gradients immediately after stent implantation decreased from 30 mm Hg (range 20–50 mm Hg) to 8 mm Hg (range 0–15 mm Hg). Five patients had one (3 pts) or two (2 pts) balloon dilations 3–28 months (median 12 months) after Growth Stent implantation. The median pressure gradient decreased from 25 mm Hg (range 15–30 mm Hg) to 15 mm Hg (range 5–25 mm Hg). Six patients received a large stent after 19–34 months. Median body weight was 11.8 kg (9.4–15 kg). Conclusions : The Growth Stent is suitable for the acute treatment of aortic coarctation in infants and can be overstented later on—if necessary—with a larger stent without causing restriction. © 2008 Wiley‐Liss, Inc.     

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.     

Simultaneous treatment of native coarctation of the aorta combined with patent ductus arteriosus using a covered stent.

A 19-year-old girl with coarctation of the aorta and patent ductus arteriosus underwent simultaneous treatment of native coarctation and closure of ductus arteriosus using a covered Cheatham-Platinum stent. This technique may be used as an alternative to other forms of interventional therapy or surgery for this combination of lesions in adolescents and adults.     

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.     

Stent implantation for aortic coarctation and recoarctation

OBJECTIVE—To determine the early results of balloon expandable stent implantation for aortic coarctation or recoarctation.
DESIGN—Prospective observational study.
SETTING—Two paediatric cardiology tertiary referral centres.
PATIENTS—17 patients, median age 17 years (range 4.4 to 45) and median weight 61 kg (17 to 92). Six had native aortic coarctation and 11 had aortic recoarctation; 14 had upper limb systolic hypertension. Of those with recoarctation, eight had had at least one previous balloon dilatation attempt and two of these patients also had further surgical interventions.
INTERVENTION—Balloon expandable Palmaz iliac stent implantation.
MAIN OUTCOME MEASURES—Systolic pressures gradients, minimum aortic diameter, upper limb blood pressures, and incidence of aneurysm formation.
RESULTS—18 stents were implanted during 18 procedures in the 17 patients. Mean peak systolic pressure gradient fell from 26 mm Hg (95% confidence interval (CI), 21 to 31 mm Hg) before to 5 mm Hg (2 to 8 mm Hg) after stent implantation (p < 0.001), and mean minimum aortic diameter increased from 7 mm (95% CI, 6 to 8 mm) before to 11.3 mm (10 to 12.6 mm) after implantation (p < 0.001). Complications occurred in five patients (bleeding in two, stent migration in two, and aneurysm formation in one). Two patients remained borderline hypertensive and eight were receiving antihypertensive treatment at most recent assessment.
CONCLUSIONS—Stent implantation for aortic recoarctation and native coarctation gives good immediate results. Careful follow up is necessary to evaluate complications and the long term effect on blood pressure.


Keywords: coarctation; aortic recoarctation; stents     

Long-term follow-up after endovascular treatment of aortic coarctation with bare and covered Cheatham platinum stents

Background

Endovascular treatment of aortic coarctation (CoA) in children and adults frequently requires stent implantation. The aim of this study was to analyze long-term results after CoA treatment with bare and covered Cheatham-Platinum^TM (CP) stents in our institution and to derive recommendations for the differential use of these stent types.

Methods

In this retrospective single institution study, 212 patients received endovascular CoA treatment with bare (n = 71) and covered (n = 141) CP stents between September 1999 and July 2021, respectively. The indications for treatment were native CoA in 110/212 patients (51.9%) and re-coarctation after primary surgical or interventional treatment in 102/212 patients (48.1%). Median patient age at endovascular CoA treatment was 18.8 years [IQR 11.9; 35.8]. Long-term follow-up was available in 158/212 patients (74.5%) with a median follow-up of 7.3 years [IQR 4.3; 12.6].

Results

Procedural success was achieved in 187/212 (88.2%) patients. Survival rate was 98.1% after 5, and 95.6% after 10 and 15 years, respectively. The probability of freedom from re-intervention was 93.0% after 5, 82.3% after 10 and 77.8% after 15 years, respectively. Freedom from re-interventions (44/158, 27.8%) did not differ between patients who received bare or covered CP stents (p = 0.715). Multivariable risk factor analysis identified previous CoA surgery (HR: 2.0, 95% confidence interval (CI): 1.1–3,9, p = 0.029), postdilatation (HR: 2,9, 95% CI: 1.1–6.3, p = 0.028) and age at intervention (HR: 0.96, 95% CI: 0.94–0.99, p = 0.002) as independent risk factors for re-intervention. Peri-procedural complications occurred in 15/212 (7.1%) patients (dissection/thrombosis of vascular access vessel: n = 9; bleeding: n = 1; stent dislocation: n = 2; aortic dissection/aortic wall rupture: n = 3). Long-term complications were observed in 36 patients and included stent fracture (n = 19), aneurysm formation (n = 14), endoleak (n = 1) and subclavian artery stenosis (n = 2). Peri-procedural and long-term complications did not differ between patients who received CoA treatment with bare or covered CP stents (all p > 0.05).

Conclusion

Endovascular treatment of CoA using bare or covered CP stents can be performed safely and effectively with excellent long-term results. Survival, re-intervention and complication rate did not significantly differ between both stent types. However, individual stent selection is advisable with regard to CoA morphology and severity as well as patient age.     

Aortic rupture following a covered stent for coarctation: delayed recognition.

Primary stenting for aortic coarctation is frequently used in adult patients. Aortic rupture remains an infrequent complication. A number of strategies, including the use of covered stents, have been proposed to reduce the risk of this catastrophic complication. We describe a 51-year-old female who underwent stenting of aortic coarctation using a covered stent, which was complicated by aortic rupture. Treatment consisted of placement of an additional covered stent to seal the site of aortic disruption. The prevention and management of aortic rupture complicating aortic coarctation stenting are discussed.     

Extra-anatomic aortic bypass for treatment of atypical aortic coarctation

Background The conventional extra-anatomic bypass is originated from the axillary’s artery and the graft size is often limited due to the small diameter of axillary’s artery. Extra-anatomic bypass graft originating from ascending aorta can improve the graft size and distal perfusion, but need sternotomy which might have higher operative risks compared with axillo-femeral bypass. We summarize our experiences of extra-anatomic bypass from ascending aorta for atypical aortic coarctation. Methods Between January 2005 and February 2008, 5 women aged from 18 to 64 years underwent extra-anatomic bypass from ascending aorta to abdominal aorta or iliac artery bypass for treatment of atypical aortic coarctation. Preoperatively, all patients had hypertension and needed anti-hypertensive medications. Systolic blood pressure was 151 ± 9 mmHg. Ankle pressure index (API) were 0.60 ± 0.23 in left and 0.56 ± 0.23 in right. Average systolic pressure gradient of aortic stenosis was 76 ± 18 mmHg. Three patients underwent concomitant cardiac operation, including coronary artery bypass grafting, Bentall procedure and atrial septal defect repair. Results There was no hospital and late mortality during 58 ± 15 months follow-up (range from 44 to 81 months). Postoperative systolic blood pressure was reduced to 126 ± 11 mmHg at the time of discharge. All patients maintained normal blood pressure without medication during follow-up. API was improved to 1.12 ± 0.24 in left and 1.17 ± 0.25 in right (compared with preoperative data, P < 0.05). Follow-up computer tomography showed patency in all grafts. Conclusions Surgical treatment of atypical aortic coarctation with extra-anatomic bypass originating from ascending aorta alleviates hypertension and low limb ischemia.     

经皮支架置入术治疗主动脉缩窄的疗效及安全性

目的　评估经皮支架置入术治疗主动脉缩窄的疗效。方法　 5例 [男性 3例 ,平均年龄(33± 9)岁 ]胸主动脉缩窄患者行经皮主动脉球囊成形术及支架置入术。结果　各例支架置入后即刻压力阶差显著减低为 (8± 2 )mmHg(1mmHg =0 133kPa) ,与术前 (73± 6 )mmHg比较 ,差异有显著性(P <0 0 0 1)。平均随访 (2 7± 12 )月 ,各例无需多种药物治疗但血压控制良好 ,收缩压平均为 (15 2± 7)mmHg ,舒张压 (91± 5 )mmHg ,与术前收缩压 (2 0 1± 8)mmHg、舒张压 (12 0± 8)mmHg比较 ,差异有显著性 (P <0 0 0 1) ,无不良事件发生。结论　经皮支架置入术治疗主动脉缩窄安全可行 ,且对患者血压控制具有长期疗效。     

Late development of dissecting aneurysm following balloon angioplasty of native aortic coarctation

Acute aortic dissection during balloon angioplasty for coarctation of the aorta or aneurysm formation during follow-up are well-known complications of this procedure. Dissecting aneurysm development during long-term follow-up after balloon angioplasty of a native coarctation has not been previously reported. We report a case in which a huge dissecting aneurysm developed 3 years after the native coarctation angioplasty procedure. The aneurysm required surgical repair. © 1995 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.     

Balloon angioplasty for an unusual aortic coarctation

Percutaneous balloon angioplasty is an alternative therapy for the treatment of the typical type of coarctation. Its associated morbidity and mortality compares favorably when compared to the standard treatment surgery. While atypical coarctations are rare, the described cases have been treated surgically. We present a case of unusually located aortic coarctation successfully treated with percutaneous balloon angioplasty. Cathet. Cardiovasc. Diagn. 43:77–80, 1998. © 1998 Wiley-Liss, Inc.     

Hybrid stenting of aortic coarctation in very low birth weight premature infant

A very low birth weight infant with severe aortic coarctation developed progressive left ventricular dysfunction and pulmonary overflow with hemorrhage, while receiving prostaglandins. To avoid morbidity from conventional surgery or percutaneous intervention, a two‐step strategy was performed at a weight of 970 g. First vascular access was obtained through sternotomy: a 3/8 mm coronary stent was deployed through a 4 French sheath in the ascending aorta; the arterial duct was clipped. At the age of 5 months, the stent was removed and the aortic arch reconstructed with an end‐to‐end anastomosis through lateral thoracotomy. This strategy was not associated with morbidity typical for premature infants with congenital heart disease. © 2012 Wiley Periodicals, Inc.     

Innovative resource utilization to fashion individualized covered stents in the setting of aortic coarctation

Objectives: We describe our experience with self‐fabricated covered stents in the setting of coarctation of the aorta (CoA). Background: Balloon‐expandable covered stents are increasingly being utilized to treat CoA in older children and adults. These stents however, are not available in the United States limiting the interventionalist's ability to treat this condition safely and effectively. Methods: Retrospective analysis and follow‐up data review of our complete experience with self‐fabricated covered stents for CoA. Stents were fashioned by suturing an appropriate length of tubular polytetraflouroethylene to a bare metal stent and deploying this stent across the coarctation in a standardized fashion. Results: Over a 9‐year period we implanted 53 balloon‐expandable stents in 49 patients with CoA. Of these 13 were self‐fabricated covered stents deployed in 13 patients (7 male). Median age at implantation was 25.4 years (range, 8.7–49.5 years) with median weight of 65.5 kg (range, 28–168 kg). Indications for stent placement were native coarctation/aortic atresia (n = 9), aneurysm formation (n = 3), and re‐coarctation (n = 1). The median systolic pressure gradient across the coarctation of 33 mm Hg (range, 12–69 mm Hg) was reduced to 3 mm Hg (range, 0–19 mm Hg) post procedure (P < 0.001). There were no deaths on median follow‐up of 44 months (range, 1–83 months). One patient developed acute contained extravasation at implantation, treated with a self‐expanding stent graft. Another patient required thrombectomy for femoral arterial thrombosis. Conclusions: Innovative application of available materials adds to the armamentarium of the interventionalist. Our self‐fabricated covered stent provides effective gradient reduction with no compromise in stent delivery or durability on follow‐up. © 2011 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.     

Balloon-expandable stents for native coarctation of the aorta in children and adolescents

Although balloon-expandable stent implantation for native aortic coarctation is a preferred method in the adolescent age group, there are insufficient data about indications for and the efficacy of the procedure in a younger age group. The aim of this study was to compare and evaluate the data of young pediatric and adolescent patients who underwent balloon-expandable stent implantation because of native aortic coarctation. The retrospective analysis included the demographic characteristics and data related to the procedure and follow-up of patients who underwent stent implantation for native aortic coarctation between August 2010 and November 2017. Patients with re-coarctation were excluded from the study. The patients were separated into 2 groups as the adolescent group (Group I: 10–18 years) and the pediatric group (Group II: ≤ 9.9 years). Group-I comprised of 18 patients and Group-II, 32 patients. Covered stent was implanted to 32 (73%) patients and uncovered stent to 12 (27%) patients. The procedural success rate was 100%. Following stent implantation, peak systolic gradient decreased significantly in both groups (P < .0001) (Group-I: from 35.9 ± 16.6 mm Hg–2.2 ± 3.4 mm Hg, Group II: from 34 ± 13.3 mm Hg–3 ± 4.09 mm Hg). Complications developed in 3 patients, and all in Group I. Femoral hematoma developed in 1 patient, balloon rupture occurred during the procedure in 1 patient, and there was temporary loss of pulse in 1 patient. All the complications were treated successfully. All the patients were taking anti-hypertensive drugs before intervention and during the mean 23-month follow-up period (range, 2–84 months), hypertension recovered in 35 (80%) patients and drugs were terminated. Stent implantation for aortic coarctation in the pediatric age group may provide pleasing results, reducing the coarctation gradient, providing effective dilatation in the lesion area and eliminating hypertension.