经皮球囊主动脉缩窄扩张术9例疗效观察

对未经外科手术的隔膜型主动脉缩窄9例患儿进行了经皮球囊扩张术,其平均年龄(4．92±3．99)岁,均经临床、心电图、X线及超声心动图检查确诊,采用比缩窄部直径大于3倍～4倍或不超过缩窄近端的主动脉直径的球囊予以扩张治疗。结果手术全部成功,高血压即刻得到控制,跨缩窄部压差由(46．80±15．30)mmHg降至(8．40±8．33)mmHg。随访下肢血压超过或接近上肢,跨缩窄压差11．25mmHg～19．50mmHg,无动脉瘤形成。我们认为经皮球囊治疗未经外科手术的隔膜型主动脉缩窄是一种疗效好、安全、操作简单的方法。     

Dilation mechanism, causes of restenosis and stenting in balloon coarctation angioplasty

This review focuses on the individual dilation mechanism, the possible cause of restenosis after balloon angioplasty and the clinical application of a stent in coarctation of the aorta. Balloon angioplasty is still not the first choice of therapy in neonates with native coarctation because of the potential risk of aortic disruption, the high incidence of restenosis and the satisfactory results of surgical coarctectomy. Intravascular ultrasound imaging provides the individual mechanism of aortic dilation by balloon, and this will be a new modality for assessing the relationship between restenosis and aortic luminal morphology after balloon dilation. Although the cause of restenosis after balloon angioplasty remains uncertain, it may be due to a combination of elastic recoil by ductal tissue constriction, intimal hyperplasia and arterial remodelling. A stent could be an effective alternative to conventional balloon angioplasty in native coarctation of the aorta, preventing ductal tissue constriction. However, the problematic relationship between patient growth and relative stenosis of the stent should be clarified before clinical application of a stent for this disease.     

Dissecting transverse aortic arch aneurysm after percutaneous transluminal balloon dilation angioplasty of an aortic coarctation

Summary Percutaneous transluminal balloon dilation angioplasty of an aortic coarctation was done in a one-day-old boy. The infant died 10 h later during aortic valvotomy. A dissecting aneurysm of the aortic arch was present at autopsy.     

Restenosis after balloon angioplasty of coarctation: Relationship with ductus arteriosus

BACKGROUND: Recently, balloon angioplasty (BA) has been used for the treatment of coarctation of the aorta (CoA) and the effectiveness of this treatment has been reported. However, the restenosis rate following BA in native CoA in the infant is high and the cause may be related to tissue properties at the origin of the ductus arteriosus (DA). However, the mechanisms responsible for restenosis remain uncertain. METHODS/RESULTS: The present study was designed to examine transformation of the smooth muscle cell (SMC) phenotypes using immunohistologic studies and to investigate the cause of restenosis of CoA following BA. A CoA model was surgically created in 15 newborn pigs (10-14-days-old; 2.4-4.1 kg). Balloon angioplasty was performed 1 month after the initial operation. One or 3 months after BA, animals were killed and immunohistologic studies on smooth muscle cell (SMC) antibodies against SM1, SM2 and SMemb of the myosin heavy chain (MHC) isoform were performed in the aorta at the CoA and DA. In the neointima, only SMemb was positive. In the SMC layer of the DA, only SM2 was positive. One month after BA, the external layer of the tunica media was strongly positive for SM2 only in the area around the origin of the DA. CONCLUSIONS: The first cause of restenosis is obstructive neointimal formation caused by the proliferation of undifferentiated SMC into the subendothelial tissue. This proliferation seems to be triggered by BA. The distribution of SM2 1 month after balloon angioplasty showed a similar pattern of proliferation of SMC in the external layer around the DA. This may represent a second mechanism of restenosis.     

先天性主动脉缩窄的诊断与治疗:附75例报告

为探讨小儿先天性主动脉缩窄的临床特点及治疗方法选择。选取１９８５年１月￣１９９８年１月主动脉缩窄７５例,行左、右心导管及升、降主动脉造影,２３例行心导管主动脉缩窄球囊扩张术。发生反复呼吸道感染４７例,心功能不全４５例,７５例均可在胸骨左缘Ⅱ￣Ⅳ肋间闻及收缩要音。血压,上肢〉下肢６０例,接近１０例,正常５例;股动脉搏动减弱６０例,正常１５例。结果：２３例心导管球囊扩张术中除３例主动脉弓发育不良效果不     

Balloon dilatation and stent implantation for vascular stenosis

BACKGROUND: Previous results show that the success rate of balloon angioplasty for pulmonary artery stenosis is low. Mortality and morbidity are significant in balloon angioplasty for coarctation of the aorta. METHODS: A review of the experience of balloon angioplasty for pulmonary artery stenosis and coarctation of the aorta at our institution was performed. A review of scientific reports of balloon angioplasty for these lesions was investigated. RESULTS: Review of our results indicates that balloon angioplasty for pulmonary artery stenosis can be performed with a high success rate (80-90%), (i) by performing it at an appropriate time, (ii) by using high-pressure balloons, (iii) by using stents, and (iv) by using intravascular ultrasound (IVUS). Major complications occurred in 3% at our institution in balloon angioplasty for pulmonary artery stenosis. Incomplete dilation has been noted in 10-25% of patients of coarctation of the aorta. Aortic aneurysm has been reported in 2-7% of patients. Re-stenosis and/or hypertension also occur. The re-stenosis rate may be decreased if the aorta is dilated until signs of intimal tear are observed. Systemic hypertension may be noted in the long term after balloon angioplasty of coarctation of the aorta, even in patients with fairly good anatomical repair. The mechanisms for hypertension are not clear, but residual stenosis, even mild, may result in upper body hypertension. CONCLUSIONS: Although there are significant limitations in the procedures, balloon angioplasty is effective in the management of pulmonary artery stenosis and coarctation of the aorta.     

Isoproterenol stress test during catheterization of patients with coarctation of the aorta

Background: The exercise test is considered useful in selecting high‐risk patients with repaired coarctation of the aorta (CoA), but it is difficult to obtain the cooperation of pediatric patients. The present study determines the feasibility of the isoproterenol stress test (IST) among pediatric patients with CoA. Methods: Thirteen patients with repaired or mild preoperative CoA aged 1–207 (median 13) months underwent 16 IST during cardiac catheterization. Peak‐to‐peak pressure gradients (PG) over the coarctation site were measured at baseline and at IST. Balloon angioplasty (BAP) was applied to patients with significant stenosis on angiography. Results: The PG between the ascending and the descending aorta was significantly higher at IST than at baseline (20.5 ± 11.5 vs 5.6 ± 3.9 mmHg, P < 0.0001). Heart rate, the systolic blood pressure measured at the ascending aorta, and pulse pressure were all significantly higher at IST than at baseline. The PG at IST decreased >10 mmHg in three of six patients after BAP. Conclusions: Significant pressure gradients over the coarctation site develop at IST in pediatric patients with repaired CoA or in preoperative patients with mild coarctation.     

Gastrointestinal hemorrhage after combined percutaneous angioplasty of aortic coarctation and valvuloplasty of aortic stenosis in an infant

Summary Gastrointestinal hemorrhage has not been previously reported as a complication of dilating left-sided obstructive lesions. This report describes an infant who developed significant intestinal bleeding after combined angioplasty for aortic coarctation and valvuloplasty for aortic stenosis.The opinions expressed are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Persistence of hypoplastic and recoarcted fifth aortic arch associated with type A aortic arch interruption: Surgical and balloon angioplasty results in an infant

Summary A rare aortic malformation, the persistence of the fifth aortic arch (PFAA) associated with coarctation of the aorta, is reported in a 3-month-old male infant who underwent an emergency surgical intervention at 10 days of life, to relieve a severe aortic coarctation by pericardial patch technique.A successful balloon angioplasty was performed 2 months later eliminating a recoarctation. The gradient fell from 77 mmHg to 0, but a definitive surgical intervention for recoarctation was necessary 14 months after angioplasty.     

IVC angioplasty using an autologous vascular graft for IVC stenosis due to metallic stent in a pediatric liver transplant

A 12‐year‐old girl underwent LDLT using a left lobe graft for hepatic dysfunction associated with citrin deficiency. A continuous anastomosis suture technique was performed between the recipient's IVC and the donor's left hepatic vein. At age 14, the patient developed intractable ascites. Venography of the IVC and hepatic vein showed twisted‐shape stenosis of the hepatic vein‐IVC anastomosis with intravascular pressure gradient, probably due to the enlarged transplanted liver, for which a metallic stent was placed. The ascites disappeared, and the patient was making satisfactory progress eight months after surgery. However, nine months after surgery, the ascites appeared again with edema in the lower extremities. Since the stent that had been inserted was suspected of hampering the outflow of the graft liver and IVC, it was decided to conduct stent removal and IVC angioplasty. After intravascular exploration, the stent was removed. Angioplasty was performed. An autologous vascular graft patch was designed to be wedge‐shaped to fit the incised part of the IVC, and it was sutured with 5‐0 non‐absorbable surgical sutures using a continuous suture technique. No postoperative complications or perioperative graft dysfunction were observed. The ascites decreased markedly, and the edema in the lower extremities disappeared. Thus, we were able to successfully perform IVC angioplasty using an autologous vascular graft patch in a patient who developed IVC stenosis after stenting. This procedure is one of the most effective treatment options, especially for pediatric patients requiring long‐term vascular patency.     

Successful stent placement for hepatic venous outflow obstruction in pediatric living donor liver transplantation, including a case series review

Abstract:  HVOO may lead to graft dysfunction in LDLT. Balloon angioplasty is the first treatment for HVOO. However, some cases with recurrent HVOO need multiple interventions and require stent placement. The authors describe a pediatric case with recurrent HVOO requiring multiple stent placements. Her symptoms related to HVOO finally disappeared after the third stenting. A year later, follow-up liver biopsy did not show any dramatic change in perivenular fibrosis. From a review of our pediatric cases with HVOO requiring stent placement, the majority of them lost the grafts, because the timing of stent placement was too late to prevent the progression of fibrosis. In conclusion, stent placement should be considered in select cases of HVOO. Serial liver biopsies evaluating the degree of fibrosis are essential in determining the timing of stent placement.     

Noninvasive assessment of coarctation of the aorta: Comparative measurements by two-dimensional echocardiography,magnetic resonance,and angiography

Summary Fifteen patients, aged between 9 and 21 years (mean, 15.1), with native coarctation of the aorta (CoA) or suspected recoarctation after surgical repair, underwent three different diagnostic procedures. Two-dimensional echocardiography (2D echo) and magnetic resonance imaging (MRI) of the thoracic aorta were performed in all patients; 14 patients underwent aortography, and digital subtraction angiography of the aorta was performed in one (after injection via a central venous catheter). Conventional electrocardiographic (ECG) gated MRI was performed, using the sagittal plane, a 256×256 acquisition matrix, multi-slice technique and a slice thickness of 10 mm. Diameters at the coarctation site were determined by all methods. Additional diameters of the descending aorta and the aortic arch were measured by MRI and echocardiography, respectively. All noninvasively obtained diameters were compared with angiographic data. Ultrasound imaging of the aortic isthmus was achieved in seven of 15 patients and of the aortic arch in nine of 15. The mean difference compared with angiographically determined diameters was 1.7 (0–7) mm, being greater for the coarctation site [mean, 2.2 (0–4)]. MRI images of the aortic isthmus were obtained in all patients, but the difference to angiographically determined diameters was slightly higher [mean, 3.2 mm (0–8)] than the ultrasound results. This deviation was presumably due to technical conditions, such as slice thickness and orthogonal imaging planes. Including all diameters, the correlation to invasive measurements wasr=0.82 (SEM=3.1) for MRI andr=0.89 (SEM=2.3) for echo recordings. It is concluded that MRI gives a reliable estimate of the severity of coarctation in a higher percentage of investigated patients. However, in patients in whom ultrasound imaging is successful, results are as reliable as those obtained by MRI.     

Esophageal atresia and tracheo-esophageal fistula associated with coarctation of the aorta,CHARGE association,and DiGeorge syndrome: a case report and literature review

CHARGE association and DiGeorge syndrome (DGS) rarely occur together and only eight cases have been reported in the English literature. Two were associated with esophageal atresia (EA) and severe congenital heart anomalies. We report a third case of EA with tracheoesophageal fistula (EA-TEF) associated with coarctation of the aorta (CoA), CHARGE association, and DGS. The challenge for management in this complicated case is the background DGS which influences surgical outcome because of Ca++ imbalance and immune deficiency that can be life-threatening and require bone marrow transplantation.     

Cheatham-Platinum支架置入术治疗儿童先天性心脏病血管狭窄的疗效评价

目的 评价NuMED Cheatham-Platinum(CP)支架置入术治疗儿童先天性心脏病(CHD)血管狭窄的即刻和早中期疗效.方法 2005年8月至2007年5月,采用CP支架置入治疗5例CHD血管狭窄(先天性主动脉缩窄1例,肺动脉狭窄4例).男3例,女2例,年龄4～15岁(中位年龄12岁),体重20～51 kg(中位体重24 kg).根据数字减影血管造影结果选择CP支架和NuMED双球囊,支架准确定位后先后充盈内外球囊扩张支架.结果 5例CHD血管狭窄进行了6次支架置入操作,共置入8只支架,均为8-zig CP支架,支架长度22～39 mm.除1例右肺动脉狭窄支架置入术中移位而于术后11个月重新置入第2只CP支架外,余4例6只支架即刻置入成功.跨狭窄段收缩压差由术前(43.43±25.61)mm Hg(1 mm Hg=0.133 kPa)降至术后(3.29±3.09)mm Hg(t=4.320,P<0.01),最窄处血管直径由术前(6.86±2.04)mm增加至术后(13.44±4.02)mm(t=-4.508,P<0.01).2例单侧肺动脉分支狭窄术后狭窄侧肺血流量占全肺血流量百分比分别由11.0%和13.0%增加至47.5%和52.2%,2例双侧肺动脉分支狭窄的右心室/主动脉收缩压比分别由术前62.3%和72.2%降至术后27.0%和33.3%.1例主动脉缩窄术后上肢血压由206/133 mm Hg降至156/95mm Hg.随访13～34个月(中位时间20个月),2只CP支架于术后6个月发生支架内再狭窄,余结果稳定无并发症发生.结论 CP支架置入术治疗儿童CHD血管狭窄安全可行,即刻和早中期疗效较好,但远期疗效有待进一步随访和更多病例的研究.