Young Erben1, Gustavo S Oderich2, Hence J M Verhagen3, Maarten Witsenburg4, Allard T van den Hoven4, Eike S Debus5, Tilo Kölbel5, Frank R Arko6, Giovanni B Torsello7, Giovanni F Torsello8, Peter F Lawrence9, Michael P Harlander-Locke9, J Michael Bacharach10, William D Jordan11, Mark K Eskandari12, Donald J Hagler13. 1. Section of Vascular and Endovascular Surgery, Yale School of Medicine, New Haven, Conn; Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. 2. Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: oderich.gustavo@mayo.edu. 3. Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. 4. Department of Congenital and Pediatric Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands. 5. Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany. 6. Division of Vascular and Endovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC. 7. Department of Vascular and Endovascular Surgery, St. Franziskus Hospital and University Clinic of Muenster, Muenster, Germany. 8. Westphalian Center for Radiology, Muenster, Germany. 9. Division of Vascular Surgery, University of California Los Angeles, Los Angeles, Calif. 10. Division of Vascular Medicine, North Central Heart Institute, Avera Heart Hospital of South Dakota, Sioux Falls, SD. 11. Division of Vascular Surgery and Endovascular Therapy, University of Alabama-Birmingham, Birmingham, Ala; Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, Ga. 12. Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill. 13. Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minn.
Abstract
OBJECTIVE: The objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults. METHODS: Clinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention. RESULTS: There were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%. CONCLUSIONS: Endovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success.
OBJECTIVE: The objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults. METHODS: Clinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention. RESULTS: There were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%. CONCLUSIONS: Endovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success.
Authors: Joshua D Kurtz; Agustin E Rubio; Troy A Johnston; Brian H Morray; Thomas K Jones Journal: Pediatr Cardiol Date: 2022-03-10 Impact factor: 1.838
Authors: Djamila Abjigitova; Mostafa M Mokhles; Maarten Witsenburg; Pieter C van de Woestijne; Jos A Bekkers; Ad J J C Bogers Journal: Eur J Cardiothorac Surg Date: 2019-12-01 Impact factor: 4.191