Endovascular stent placement is an acceptable alternative to reoperation in selected infants with residual or recurrent aortic arch obstruction

Objective : To describe endovascular stent placement in infants as a technically feasible option in circumstances where surgery is considered less favorable. Background : Endovascular stent placement has become established as a first line therapy for native coarctation of the aorta or recoarctation in older children where stents capable of expansion to adult size can be placed safely. Surgery remains the therapy of choice in infants and young children. The management of aortic arch obstruction in infants is, however, frequently complicated by complex anatomy or clinical condition that may make surgery or further surgery an unattractive option. There is little reported data and the implications thereof of transcatheter stent placement in aortic arch obstruction in infants. Methods : Between August 2004 and November 2009, 11 patients had aortic arch obstruction treated with endovascular stent placement. The median age and weight at first stent placement was 46 days (range 3–399 days) and 4 kg (range 1.4–8 kg), respectively. In 10 patients, surgical intervention preceded transcatheter stent placement. Four had complex aortic arch obstruction and seven had recoarctation. Results : Reduction in peak systolic gradient to <10 mm Hg was achieved in seven of 10 patients with an improvement in aortic artery diameter to >90% of adjacent aorta in all. The diameter of the arch obstruction increased from a median of 1.60 to 4.90 mm (P = 0.001) and the peak systolic gradient from 45 mm Hg to 8 mm Hg (P < 0.0001). Adverse events occurred in two patients one who required further surgical revision and a second who required placement of a second stent. The median follow up was 3.60 years (range 0.4–5.5 years) with two patients having died at 1.34 and 1.42 years poststent placement. Of the nine patients alive, six have since undergone further angioplasty at a median time interval of 0.77 years (range 0.17–2.76 years). Long‐term complications occurred in none. Conclusions : Endovascular stent placement in infants is technically feasible with good results achievable even in small babies. It should be considered as a therapeutic option in complex cases when surgical alternatives are less favorable. © 2010 Wiley‐Liss, 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.     

Endovascular stents for coarctation of the aorta: initial results and intermediate-term follow-up.

OBJECTIVES: The aim of this study was to evaluate the use of endovascular stents in native and recurrent coarctation of the aorta (CoA). BACKGROUND: Stents have been used successfully in various locations. Their use in CoA can be an alternative to surgery or balloon angioplasty (BA). METHODS: Thirty-four patients with CoA (13 native and 21 re-coarctation after surgery or BA) with a mean age of 16 +/- 8 years (range 4 to 36 years) underwent attempted stent implantation between 1993 and 1999. Successful outcome was defined as peak systolic pressure gradient after stent implantation < 20 mm Hg. RESULTS: Stents were implanted in 33/34 patients, and successful outcome occurred in 32/33 patients. Peak systolic pressure gradient decreased from 32 +/- 12 mm Hg to 4 +/- 11 mm Hg (p < 0.001). Coarctation site to descending aorta diameter ratio increased from 0.46 +/- 0.16 to 0.92 +/- 0.16 (p < 0.001). Two patients underwent successful stent re-dilation 16 and 21 months after initial implantation. Six patients (18%) developed complications, including two patients who underwent surgery. Follow-up for 29 +/- 17 months (range: 5 to 81 months) demonstrated no evidence of re-coarctation, aneurysm formation, stent displacement or fracture. Systolic blood pressure (SBP) decreased from 136 +/- 21 mm Hg before stent placement to 122 +/- 19 mm Hg at follow-up (p = 0.002). The SBP gradient decreased from 39 +/- 18 mm Hg to 4 +/- 6 mm Hg, and peak Doppler gradient decreased from 51 +/- 26 mm Hg to 13 +/- 11 mm Hg at follow-up (p < 0.001). CONCLUSIONS: Intravascular stent placement for native and recurrent CoA has excellent results in the short and intermediate terms. Long-term outcome remains to be evaluated.     

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.     

Implantation of balloon-expandable stents for coarctation of the aorta: Implantation data and short-term results

We report the immediate results and the short-term follow-up in a group of selected patients with coarctation of the aorta who underwent endovascular stent implantation. Balloon-expandable stents were implanted in 6 patients (mean age 19.8 ± 5.1 years) with coarctation of the aorta (4 recurrent and 2 native) who underwent a total of 7 procedures (6 implantation and 1 further expansion). The systolic peak pressure gradient was decreased from 36.7 ± 16.9 to 13.3 ± 23.2 mm Hg (P < 0.005). There was a 66% increase in the mean coarctation diameter from 9.3 ± 1.7 to 15.6 ± 3.1 mm (P = 0.001) with the ratio of the coarctation to descending aorta diameter, measured at the level of the diaphragm, increasing from 0.49 ± 0.1 to 0.81 ± 0.2 (P < 0.005). The dilatation was successful in expanding the stent to an acceptable diameter in 5 of 6 patients. One patient underwent successful further expansion of a stent implanted 22 months previously. There were no immediate complications during balloon expansion and stent implantation. One patient suffered a femoral arterial bleed requiring surgical repair. There was one unrelated death. All patients were hypertensive (systolic blood pressure >140 mm Hg) prior to stent implantation. At mean follow-up of 8 months, 3 patients are normotensive. There was no recurrence of coarctation, aortic dissection, or aneurysm formation in the patients in whom stent implantation was successful. These findings indicate that balloon-expandable stent implantation for coarctation of the aorta in selected patients is a safe and effective alternative approach for relieving the obstruction with a low complication rate and no recoarctation at short-term follow-up. © 1996 Wiley-Liss, Inc.     

Simultaneous stent implantation to treat bifurcation stenoses in the pulmonary arteries: Initial results and long‐term follow up

Background : Balloon angioplasty of bifurcating pulmonary artery (PA) stenoses is often inadequate, and stent treatment often requires simultaneous implantation of two stents. This study evaluates initial results and long‐term follow up of transcatheter stent placement in bifurcating PAs. Methods : This is a retrospective review of patients (pts) who had bifurcating PA stents placed in main and lobar branches from 1993 to 2007. Results : Forty‐nine pts had bifurcating PA stents placed at a median age of 10.9 years (range 1–43 years). The mean minimum vessel diameter increased from 5.7 ± 2.5 mm to 11.0 ± 3.6 mm (P < 0.001), the mean gradient across the stenoses decreased from 37.0 ± 26.9 to 9.2 ± 13 mm Hg (P < 0.001), whereas the mean RV:FA ratio decreased from 0.76 ± 0.29 to 0.53 ± 0.24 (P < 0.001). There was one death due to severe pulmonary hemorrhage. F/U data were available in 38 pts (mean duration 6.3 ± 4.1 years, range 1.2–13.1 years). Thirty pts underwent repeat catheterizations (mean 2.3 ± 2.2 years poststent), with 26 requiring further interventions: Fifteen had balloon angioplasty alone and 11 had additional stents placed. There were no complications at f/u catheterization. Six pts underwent further palliative surgeries, although none for repair of branch PA stenoses. Conclusions : Simultaneous transcatheter placement of bifurcating PA stents provides immediate gradient relief of bifurcating stenoses in the proximal or lobar branch PAs and reduces RV systolic pressure. Further interventions can be safely performed in future procedures, and the presence of stents does not complicate future surgeries. © 2009 Wiley‐Liss, Inc.     

Self‐expanding and balloon expandable covered stents in the treatment of aortic coarctation with or without aneurysm formation

Objectives: We describe our complete experience with covered stent implantation for aortic coarctation including short‐ to medium‐term outcomes. Background: Coarctation of the aorta is a heterogeneous disease process with multiple associated complications both with and without treatment. Covered stents have evolved to provide greater support to the aortic wall and a varied approach with choice of stent tailored to the anatomy of the patient is required. Methods: We retrospectively analyzed consecutive patient data from two congenital heart centers from March 2003 to October 2007. Results: We implanted 38 covered stents in 37 patients (20 female) of which three were self‐expanding stents. Median age was 29.6 years (9–65) with median weight of 71.5 kg (35–95). The indications for stent placement were native coarctation (n = 13); recurrent coarctation following surgical treatment (n = 11); aneurysm associated with previous coarctation surgery (n = 7); aorto‐bronchial fistula leading to acute hemoptysis (n = 2); stent fracture (n = 1); associated arterial duct (n = 2). One patient had a combination of acquired coarctation and false aneurysm. The median screening time was 10 min (3–22). The median systolic gradient of 26 mm Hg (10–60) was reduced to 4 mm Hg (0–20) postprocedure (P < 0.001). There were no deaths on median follow up of 11.5 months (1–56). One patient developed aortic rupture during the procedure and required emergency surgery. Conclusion: Covered stent implantation for treatment of aortic coarctation is safe and highly effective in selected patients. Self‐expanding stent grafts may be preferable to balloon expandable stents when there is aneurysm formation in the setting of aortopathy. © 2008 Wiley‐Liss, Inc.     

Results of stent implantation for native and recurrent coarctation of the aorta—follow‐up of up to 13 years

Background: To evaluate the mid and long‐term prognosis after stenting of native or recurrent CoA, we studied the cardiovascular parameters in the follow‐up period up to 13 years. Methods and results: Between 1993 and 2006, 68 patients underwent stent implantation for aortic coarctation (average age 25.5 years, range 5.7–65 years, average weight 65.5 kg, range 32–122 kg). Forty‐six (68%) patients were aged >17 years. Stenting was performed for native coarctation in 41 and for recurrent coarctation in 27 patients, in 23 (34%) patients with a covered stent. Redilation was carried out in 26 (38%) patients. The invasive systolic gradient decreased from mean (±SD) 25 (±15) mm Hg to 5 (±5) mm Hg (P < 0.0005). The descending aorta pressure increased from 80 (±15) mm Hg to 101 (±18) mm Hg. The systolic right arm blood pressure decreased from a mean of 153 (±24) mm Hg to 129 (±18) mm Hg (P < 0.0005). Complications like small dissections were rare. Follow‐up (6 days to 13 years, mean 41 months) was available in 66 patients, in 23 after reintervention at a mean of 71 months, range of 8 months to 10.3 years. Fifty‐one percent remained clinically hypertensive. Conclusions: Stenting of aortic coarctation gives good medium‐term results. Frequent reintervention relate to deliberately under‐dilating stents during the initial procedure. The reintervention rate has reduced since the introduction of covered stents. © 2011 Wiley‐Liss, Inc.     

Arthroplasty in congenital aortic coarctation in adults with balloon and endovascular prosthesis: immediate results and 6-month follow-up

Up to 1982, surgery was the treatment of aortic coarctation, with postsurgical recoarctation in 39% of cases. Since 1984 balloon aortoplasty has been performed successfully in adolescents and adult patients. We present the immediate results, and more than six months follow up of 6 patients with congenital aortic coarctation, who underwent this procedure. Five of the six patients were male, with an average age of 28.6 years (15-46), and in 4 of them a stent was placed. Systolic pressure of ascending aorta decreased from 187.1 mm of Hg (+/- 41.8) to 128 (+/- 25.4), and transaortic gradient from 66 mm of Hg (+/- 21.8) to 4.8 (+/- 7.6). Coarctation luminal diameter increased from 4.6 mm (+/- 1.41) to 14.3 (+/- 3) in patients with only balloon aortoplasty and to 17.8 mm with stent placement, p = NS. Angiography in three patients with stent at 6 months did not reveal restenosis, all six patients require less antihypertensive medications. Acute and chronic complications, percentage and time of restenosis, long term results, and possible benefit of stents are yet to be determined.     

Use of Balloon-Expandable Stents for Coarctation of the Aorta: Initial Results and Intermediate-Term Follow-Up

Objectives. In this study we report our preliminary results and intermediate-term follow-up (up to 3.5 years) of stent implantation for coarctation of the aorta (COA).

Background. Balloon angioplasty has gained acceptance as a modality of treatment for COA. Some patients do not respond optimally to balloon angioplasty alone. Balloon-expandable stents have been used in pulmonary arteries and large systemic arteries such as the femoroiliac vessels, with a significant improvement in vessel patency and a reduction in the pressure gradient compared with balloon angioplasty alone.

Methods. Nine patients (>10 years old) with COA in whom balloon dilation alone was thought to be ineffective underwent stent implantation. Seven patients had a previous operation or balloon dilation, or both, to relieve their coarctation but had a significant residual/recurrent gradient.

Results. At the time of stent implantation, the systolic and mean gradients decreased from a mean (±SEM) of 37 ± 7 and 14 ± 3 mm Hg to 4 ± 1 and 2 ± 0.6 mm Hg, respectively (p ≤ 0.002). The coarctation diameter increased from a mean of 9 ± 1 to 15 ± 1 mm (p < 0.002). The patients have been followed for up to 42 months (mean 18, median 13) with no complications; the stents remain in position with no fracture. One patient underwent further successful dilation 3 years after stent implantation because of an exercise-induced gradient. No other intervention has been required. The systolic gradient at latest follow-up is 7 ± 2 mm Hg. Only two (a 44-year old with diabetes and a 50-year old with long-standing hypertension) of five patients previously requiring antihypertensive treatment still remain on medications for blood pressure control.

Conclusions. The use of stents in COA is a feasible alternative to surgical repair or balloon angioplasty in selected patients with an effective gradient reduction. Intermediate-term follow-up shows excellent gradient relief, with no complications in this group of patients.     

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.     

Endovascular abdominal aortic stenosis treatment with the optimed self‐expandable nitinol stent

Purpose: To evaluate the safety and feasibility of self‐expandable stents (OptiMed) for treatment of abdominal aortic stenosis in the situations in which the aortic stenosis locates near the origin of celiac, superior mesenteric, renal and inferior mesenteric arteries. Methods: Five consecutive patients scheduled for endovascular treatment of abdominal aortic stenosis by self‐expandable nitinol stent (Sinus‐Aorta/OptiMed) implantation. The diameter of the stent was chosen as 10–30% more than that of the normal portion of the aorta above the stenosis. Long stents of 60 mm or longer were chosen. After stent deployment, balloon postdilation was performed with a balloon in patients with residual gradient > 5 mm Hg. Results: All patients were successfully treated with the OptiMed stents. The balloon predilation was performed in one patient due to severe stenosis. The mean diameter and length of the stents deployed were 20.4 ± 2.9 (range, 16–24 mm) and 64 ± 8.9 (range, 60–80 mm), respectively. The balloon postdilation was performed in all cases. The mean diameter of the balloons was 13.6 ± 1.5 (range, 12–15 mm). The mean diameter of stenosis increased from 4.8 ± 1.9 to 14.4 ± 1.8 mm after stent placement. The mean peak systolic gradient decreased from 46.8 ± 31.5 mm Hg to 0.8 ± 1.8 mm Hg. During follow‐up (22.8 ± 14.3 months), none of the patients had restenosis within the stent, occlusion of any branches of the aorta, or other related complications. Conclusions: In our small series, we observed that abdominal aortic stenosis can be successfully and effectively treated with OptiMed stents in the situations in which the stenotic segment is located next to the origins of the main visceral branches of abdominal aorta. © 2009 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.     

Endovascular stent implantation in patients with stenotic aortoarteriopathies: early and medium-term results.

Data regarding stent implantation for stenotic aortoarteriopathy (SAA) are incomplete. We report on nine patients with this rare syndrome who underwent arterial stent implantation. Indications, results, and complications for patients with SAA were reviewed. Nine patients underwent 11 procedures. Twenty-two stents were implanted in the aorta or brachiocephalic vessels. Five patients had diffuse stenoses, three patients had middle aortic syndrome, and one patient had thoracic and abdominal coarctation. Associated diagnoses included Williams syndrome (2), neurofibromatosis (2), Takayasu's (1), and congenital rubella (1). Median gradient was 60 mm Hg (20-140 mm Hg). Poststent gradient was 15 mm Hg (0-60 mm Hg; P < 0.001). Additional stents were implanted in two patients and five underwent stent redilation. Two patients (22%) were found to have aneurysm formation. Stent implantation effectively provides gradient relief in SAA. Gradient reduction persists or is amenable to redilation. Importantly, however, uncomplicated stent implantation does not preclude aneurysm formation and may be more common than in traditional patient groups.     

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.     

Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up

OBJECTIVES—To test the hypothesis that endovascular stents used with dilation of coarctation of the aorta (CoA) improve late outcomes. Balloon dilation for CoA has been limited by concerns over the risk for acute dissection, late restenosis, or aneurysm formation.
DESIGN—All patients seen with CoA between November 1994 and September 1997 underwent attempted stent implantation. Follow up was obtained for all patients and a subgroup (n = 18) had repeat catheterisation at a mean (SD) of 1.3 (0.5) years to assess residual gradient and stent-CoA morphology.
RESULTS—Stents were placed in 27 patients (15 male and 12 female patients, mean age 30.1 (13.1) years), of whom seven had prior surgical coarctectomy and one had a prior balloon dilation. Hypertension was present in 26 patients (mean pressure 164 (26)/86 (13) mm Hg), of whom 16 were on antihypertension drugs. CoA gradients were 46 (20) mm Hg (range 18-106 mm Hg) at baseline and 3 (5) mm Hg after the procedure. One patient had a stroke following the procedure; another patient had incomplete dilation and underwent a second procedure. At 1.8 (1) years after the procedure the mean pressure was 130 (14)/74 (11) mm Hg with seven patients on antihypertension treatment. The clinical gradient was 4 (8) mm Hg (range 0-32 mm Hg). At follow up angiography, the mean gradient was 4(6) mm Hg, and two patients had a gradient over 10 mm Hg. Aneurysms formed in three patients at the dilation site; one patient was referred for surgery.
CONCLUSION—In this age group stent management for CoA appears to be an effective technique and results in sustained reduction in CoA gradients at early term follow up, but aortic aneurysm was detected in 17% of patients who had repeat angiography.


Keywords: angioplasty; coarctation of the aorta; congenital heart defects; stents     

Self- and balloon-expandable stent implantation for severe native coarctation of aorta in adults

Background

Balloon angioplasty for native coarctation of the aorta (CoA) in adults, though promising, is sometimes limited by significant residual gradient (>20 mm Hg). Few studies available have reported on use of balloon-expandable stents in such a situation. We evaluated the use of self- and balloon-expandable stents in patients with suboptimal response to balloon angioplasty (BA).

Methods

Twenty-one hypertensive patients (age, 18 to 61 years; mean, 28.6 ± 11.2 years) with native CoA and in whom results of BA were suboptimal (ie, residual peak systolic gradient [PSG] >20 mm Hg) underwent stent implantation. Balloon-expandable Palmaz stents were implanted in 5 patients (group A) and self-expandable nitinol aortic stents in the remaining 16 patients (group B).

Results

In group A, PSG decreased from 62.8 ± 10.6 (53 to 80) mm Hg to 28.1 ± 6.3 (22 to 39) mm Hg after BA. Systolic gradient further decreased to 8.3 ± 3.9 (2 to 16) mm Hg (P < .001) after implantation of the balloon-expandable Palmaz stent. In group B, PSG decreased from 70.2 ± 24.6 (40 to 110) mm Hg to 28.4 ± 9.8 (22 to 42) mm Hg after BA and further reduced to 9.0 ± 5.5 (4 to 16) mm Hg (P < .001). One of these patients had a nitinol self-expandable stent implanted after a Palmaz stent embolized immediately after deployment. Nitinol stents were easier to deploy and conformed better to aortic anatomy compared with balloon-expandable stents. In group A, the diameter of the coarcted segment increased from 3.8 ± 0.8 mm to 13.3 ± 0.8 mm (P < .001) after stent implantation and in group B it increased from 4.5 ± 1.1 mm to 14.1 ± 2.1 mm (P < .001). There was no significant difference between the two groups in the PSG and diameter of the coarcted segment before and after stent implantation. With the exception of one case, in which a Palmaz stent embolized, there was no other complication in our series. On follow-up of 12 to 71 months (mean, 40.7 ± 5.8 months) all the implanted stents remained in their original position and none showed evidence of fracture. Improvement in hypertension was seen in 20 of 21(95.2%) of the patients. On recatheterization and angiography 1.2 ± 0.6 years after implantation in 19 patients, one patient showed an increase in PSG to 27 mm Hg across the nitinol stent and underwent successful redilation. No increase in gradient was seen in other patients. Beneficial late remodeling was seen in 10 of 14(71.4%) of patients restudied after implantation of self-expandable stent. None of the patients showed aneurysm formation.

Conclusions

Stent implantation is safe and effective in improving suboptimal results after BA for CoA. Self-expandable stents were easier to implant, adapted better to the wall of the aorta, and in most patients had similar efficacy in reducing coarctation as balloon-expandable stents.     

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.     

Endovascular Stenting for Native Coarctation of the Aorta Is an Effective Alternative to Surgical Intervention in Older Children

Objective. Assess the early and intermediate results with respect to blood pressure control in older children undergoing endovascular stenting for native coarctation of the aorta. Design. Eleven hypertensive patients (10 ± 3 years of age) underwent endovascular stenting via standard techniques for native coarctation of the aorta as an alternative to surgical repair. Resting and exercise assessment of blood pressure control with Doppler echocardiography was performed pre‐ and poststenting. Results. All 11 patients underwent successful stenting without complications and were able to be weaned off antihypertensive medications within a short period of time. At latest follow‐up (34 ± 26 months), all patients are normotensive at rest and during treadmill exercise stress testing. Two patients underwent uncomplicated additional stent dilation at follow‐up cardiac catheterization. Conclusion. Endovascular stenting for native coarctation of the aorta in older children is a reasonable alternative to surgical correction. During early follow‐up, stenting effectively alleviates the aortic arch obstruction with normalization of the systemic blood pressure both at rest and during maximal exercise.     

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.