Late Hypertension in Patients with Repaired Aortic Coarctation

Coarctation of the aorta represents more than a simple obstructive lesion, as there is often evidence of hypertension and vascular dysfunction despite successful surgery at an early age. There are ample data showing that a large proportion of patients develop arterial hypertension, and this appears to increase with age. Our understanding of the pathogenesis of late hypertension is incomplete, and there is limited information on which drugs are most appropriate. Increased arterial rigidity is now well described in this patient group, although it is not known how this should influence therapy. The increase in afterload associated with this increased rigidity has been found to have an impact on the left ventricle at an early stage, and the interaction between the vascular dysfunction and the ventricle is an area of interest and active research. This article reviews some recent studies and highlights areas where research questions remain.     

先天性主动脉缩窄合并严重主动脉瓣病变的一次性外科矫治

目的 :探讨先天性主动脉缩窄合并严重主动脉瓣病变的外科治疗方法。方法 :采用升主动脉—腹主动脉人工血管转流术 +主动脉瓣置换术一次性治疗患者 9例 ,其中 4例对手术方法和体外循环技术进行了改进。结果 :术中死于体外循环意外 1例 ;术后部分肠梗阻 1例 ,8例患者痊愈出院。上肢收缩压术后较术前下降〔平均12 2 /78mmHgvs .178/6 5mmHg( 1mmHg =0 133kPa)〕 ,有显著性差异 (P <0 0 5 ) ,术后上、下肢血压无明显压差。左心室舒张末期内径术后较术前缩小 ( 4 9 40± 6 88mmvs .6 7 33± 17 2 9mm) ,有显著性差异 (P <0 0 5 )。结论 :该类患者采用升主动脉—腹主动脉人工血管转流术 ,在常规体外循环下行主动脉瓣置换术即简便又安全有效     

Functional Health Status Late after Surgical Correction of Aortic Coarctation

Objectives. To investigate functional health status among adults previously operated for aortic coarctation (CoA) compared with healthy subjects; to assess the influence of medication and exercise capacity on patients' functional health. Design. Questionnaire‐based investigation among 119 patients who underwent surgical repair of CoA during 1965–1985 and 36 age‐ and gender‐matched healthy subjects using the SF‐36 health survey. Original scores were transformed into norm‐based scores, and summary scale scores were calculated. Exercise capacity was measured by symptom‐limited bicycle ergometer testing. Setting. Tertiary referral center. Patients. Among 156 current survivors, 119 (74 males) participated in the study. Median age (range) at repair was 11 (0.1–40) years and 44 (26–72) years at follow‐up. Outcome Measures. Comparison of all components of SF‐36 survey between patients and controls, as well as within patients regarding use of cardiovascular medication and exercise capacity. Results. Norm‐based physical functioning scores were significantly lower among patients compared with controls (51.8 ± 7.1 vs. 54.3 ± 4.7, P < 0.05). Patients using antihypertensive medication scored significantly lower in all physical categories (physical component summary= 48.9 ± 10.4 vs. 54.9 ± 4.9, P < 0.05) as well as in vitality (46.4 ± 10.5 vs. 51.4 ± 10.4, P < 0.05). Patients with reduced exercise capacity scored significantly lower in several mental and physical categories compared with patients with normal exercise capacity (physical component summary= 49.7 ± 10.7 vs. 54.0 ± 6.2, P < 0.05; mental component summary= 44.9 ± 14.6 vs. 50.1 ± 10.0, P < 0.05). Conclusion. Functional health status in patients late after CoA repair is only slightly impaired when compared with controls. However, the subgroup with reduced exercise capacity and need for cardiovascular medications have significant impairment on both physical and mental aspects of functional health.     

Aortic Aneurysm 31 Years after Coarctation Repair with Direct Anastomosis

BACKGROUND: Despite primary success, 9% of patients develop aortic (pseudo)aneurysms after surgical repair of aortic coarctation at or near the site of repair late after operation. CASE STUDY: A chest X-ray in a 32-year-old asymptomatic man, 31 years after coarctation repair, depicted a ballooning of the distal aortic arch. A multislice CT confirmed an aneurysm. The aneurysm was resected using selective head perfusion. CONCLUSION: At follow-up of patients after coarctation repair, one should anticipate aneurysm formation, even decades after successful surgery and even if clinically silent. Therefore, the chest X-ray should be part of the follow-up examination. Deep hypothermic circulatory arrest can be avoided in selected patients.     

Thoracic Aortic Frontier: Review of Current Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR)

Thoracic endovascular aortic repair, a minimally invasive technique is replacing the maximally invasive gold standard of thoracotomy and replacement of the descending thoracic aorta. With experience, indications have expanded to encroach on the arch and even ascending aorta. This review highlights the current state of technology, discusses controversies, and takes the perspective of a forward-thinking review to describe novel, innovative techniques that might make the entire thoracic aorta amenable to minimally invasive repair.     

Endovascular Aortic Repair in Nonagenarian Patients

BackgroundThe increasing proportion of elderly patients being treated for abdominal aortic aneurysm (AAA) in the endovascular era is controversial.ObjectivesThis study compared 30-day outcomes of endovascular aortic repair (EVAR) in nonagenarians (NAs) with non-nonagenarians (NNAs).MethodsThis retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database included EVAR procedures performed from 2011 to 2017. Multivariate logistic regression in the unadjusted cohort, followed by propensity-score matching (PSM), was performed. Primary outcomes were 30-day mortality and 30-day major adverse events.ResultsA total of 12,267 patients were included (365 NAs). Ruptured aneurysms accounted for 6.7% (n = 819): 15.7% (n = 57) in NAs versus 6.5% (n = 762) in NNAs (p < 0.001). Mean aneurysm diameter was 6.5 ± 1.8 cm in NAs versus 5.8 ± 1.7 cm in NNAs (p < 0.001). The unadjusted 30-day mortality was 9.9% in NA versus 2.2% in NNAs (p < 0.001). Multivariate analysis revealed age ≥90 years (odds ratio [OR]: 3.36), male sex (OR: 1.78), functional status (OR: 4.22), pre-operative ventilator dependency (OR: 3.80), bleeding disorders (OR: 1.52), dialysis (OR: 2.56), and ruptured aneurysms (OR: 17.21) as independent predictors of mortality. After PSM, no differences in 30-day mortality (intact AAA [iAAA]: 5.3% NA vs. 3% NNA [p = 0.15]; ruptured AAA [rAAA]: 38% NA vs. 28.6% NNA [p = 0.32]) or 30-day major adverse events (iAAA: 7% NA vs. 4.6% NNA [p = 0.22]; rAAA: 28% NA vs. 36.7% NNA [p = 0.35]) were observed.ConclusionsAge was identified as an independent predictor of 30-day mortality after EVAR on multivariate analysis. However, no differences were found after PSM, suggesting that being ≥90 years of age but with similar comorbidities to younger patients is not associated with a higher short-term mortality after EVAR. Age ≥90 years alone should not exclude patients from EVAR, and tailored indications and carefully balanced risk assessment are advised.     

Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience

Background/PurposeCoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks.Materials/MethodsA retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done.Results18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10–45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications.ConclusionsEndovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.     

Endovascular Repair of a Traumatic Thoracic Aortic Injury Resulting in Late Aortic Dilatation

We present an unusual complication following endovascular repair of traumatic thoracic aortic injury using a homemade stent-graft. Although an initial technical success was apparently obtained, the aorta showed remarkable dilatation without shortening or migration of the stent skeleton in late follow-up period. The possible cause of the dilatation was considered to be the expansion and gathering of the crimped, loosely attached, graft fabric in addition to the incomplete exclusion due to the insufficient landing zone and the limited radial force. Thus, the specific feature of stent-graft, considered to provide an advantage to treatment, has adversely affected the native aorta.     

Infective Endarteritis and Mycotic Pseudoaneurysms in a Pediatric Patient With Aortic Coarctation

An 11-year-old boy presented with Staphylococcus aureus infective endarteritis and mycotic pseudoaneurysms within the context of a previously undiagnosed aortic coarctation. He had an urgent resection of the pseudoaneurysm and coarctation repair. Nuances to his initial diagnosis and key learning points related to the complication of pseudoaneurysm are discussed.