Sequential dilation strategy in stent therapy of the aortic coarctation: A single centre experience

https://doi.org/10.1016/j.ijcard.2021.01.038Get rights and content

Highlights

  • Endovascular stent implantation is effective means for aortic coarctation treatment.

  • With the sequential dilation of the CoA-stent, a low rate of mortality can be achieved.

  • It also has a very low rate of life-threatening aortic complications.

  • It should be considered for patients with high risk for aortic complications.

Abstract

Background

In our study, we sought to analyse the mid-term results after interventional aortic coarctation (CoA) stenting with sequential dilation of the stent.

Methods

The data of all 218 patients, who are above the age of 6 years and underwent CoA-stent implantation in our hospital, were retrospectively analysed on the rate of re-interventions, complications and arterial hypertension at a follow-up time of 31 months. To avoid any aortic complications, stents were deployed primarily not in full size and a second cardiac catheterisation for further dilatation was scheduled within 6–12 months after the stent implantation.

Results

The median peak invasive systolic pressure gradient declined significantly from 26.2 mmHg to 2.7 mmHg after stenting. There was one procedure related death due to an aortic rupture after stent implantation. There were in total 33 (15.1%) procedure-related complications including femoral artery complications, stent fracture and stent dislocation (in 9, 9 and 7 patients, respectively). In 85 patients a re-dilatation and in 25 patients a second stent-implantation was necessary at the first re-intervention. The systolic blood pressure declined significantly from 144 mmHg to 131 mmHg after stenting. The number of patients being normotensive changed from 18% before stenting to 78.5% after stenting with adjusted antihypertensive medication.

Conclusion

Aortic stenting is an effective means for CoA treatment. With sequential dilation of the stent, a very low rate of life-threatening procedural complications and mortality can be achieved. CoA stenting with proper antihypertensive medications results in better control of blood pressure.

Introduction

Coarctation of the aorta (CoA) is defined as a significant narrowing of the aortic isthmus, at the insertion of the arterial band [1]. It accounts for 5%–8% of all congenital heart defects and is considered as a part of a generalized arteriopathy, associated with valvulopathy, vasculopathy and cerebrovascular disease [[1], [2], [3], [4]].

Surgery and catheter interventional techniques are available alternatives for management of CoA. Even if the surgical results are excellent and repair can be performed with freedom from major complications in most of the patients [5], survival remains limited due to comorbidities such as arterial hypertension and re-interventions/re-operations needed in long term follow-up [6,7]. One of the most frequent reasons leading to a re-intervention or re-operation is the recurrent coarctation of the aorta (Re-CoA) after its surgical or interventional treatment.

Over the last 20 years, stent implantation has become the treatment of choice for native CoA and Re-CoA in older children, adolescents and adults in many cardiac centres. A perceived higher risk associated with open surgery in particular with repeated surgery for CoA, and a convenience argument -lack of thoracotomy scar, reduction of physical impairment, shorter hospital stay- for the patient has facilitated this shift [8,9]. In this study, we report the midterm results in children, adolescents, and adult patients who underwent endovascular stent placement for both native CoA and Re-CoA regarding complications, re-interventions and arterial hypertension as a most important concomitant phenomenon of aortic coarctation.

Section snippets

Study subjects

We retrospectively analysed the data of all consecutive patients, who underwent cardiac catheterisation for native and recurrent aortic coarctation at German Heart Centre Munich between February 1999 and October 2017.

The goal of the study was to evaluate the rate of reinterventions, procedure-related complications and the course of blood pressure following aortic coarctation stenting at a median follow-up time of 31 months (range 0–216 months).

Only patients above 6 years old were included in

Patients

There were 218 patients treated with an interventional stent implantation. A total of 101 patients (46.3%) were diagnosed with native CoA and 117 patients (53.7%) developed Re-CoA after surgical correction (84 patients with end to end anastomosis,13 patients with graft interposition, 16 patients with aortic arch reconstruction, 4 patients with subclavian flap). From Re-CoA patients, 22 patients had more than one surgical operation for recurrent CoA. The detailed patient characteristics are

Discussion

This study shows, that CoA stenting is an effective means for treatment of native – and recurrent coarctation (Re-CoA). With sequential dilation of the CoA-Stent, a very low rate of life-threatening procedural complications and mortality can be achieved. CoA stenting with proper antihypertensive medications results in better control of blood pressure.

In many cases, a Re-CoA can be successfully treated with a balloon angioplasty and an open surgery can be avoided. However, with a balloon

Conclusion

The intermediate outcome of our study with 218 patients and a median follow-up time of 31 months, is encouraging for endovascular stent implantation as a treatment of choice in patients with native and recurrent aortic coarctation. The mortality is low and with sequential dilation of the CoA-stent, major complications can be avoided. Furthermore, CoA stenting with proper antihypertensive medications results in better control of blood pressure. However, patients with a CoA, those with surgical

Funding statement

MF is funded through a research grant from the Egyptian Ministry of High Education (PhD Scholarship).

Author statement

  • Conception and design of the study: PBH, MF, AH, SC, SG, DT, PE, JH, AE

  • Acquisition of the data: PBH, MF, SC, SG, DT, PE, AE

  • Analysis and/or interpretation of the data: PBH, MF, AH, SC, AE

  • Drafting the manuscript: PBH, MF, AE

  • Revising the manuscript critically for important intellectual content: PBH, MF, AH, SC, SG, DT, PE, JH, AE

  • Approval of the version of the manuscript to be published: PBH, MF, AH, SC, SG, DT, PE, JH, AE

Declaration of Competing Interest

None declared.

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    1

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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