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Mortezaeian H, Rezanejad E, Pasebani Y, Zamani R, Khalili Y, Ghaemi H, Jafari F, Sabri M, Moosavi J, Mohebbi B, Abdi A, Montazeri Namin S, Sadeghipour P, Haulon S, Fraisse A. Five-Year Outcomes of Coarctoplasty with Stents in the Pediatric Population: Results from a Retrospective Single-Center Cohort with Centrally Adjudicated Outcomes. Pediatr Cardiol 2024:10.1007/s00246-024-03551-4. [PMID: 38940826 DOI: 10.1007/s00246-024-03551-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
Transcatheter stent implantation is a widely performed procedure for treating native coarctation of the aorta (CoA) in pediatric patients. However, data on mid- to long-term outcomes are limited. The aim of this study was to evaluate the mid-term safety and efficacy of transcatheter CoA stenting based on centrally adjudicated outcomes. This retrospective cohort study included patients aged 15 years or younger undergoing de novo stenting for CoA or recoarctation (reCoA) between 2006 and 2017. Immediate and 5-year outcomes were assessed. Immediate outcomes (procedural and in-hospital) were retrieved from electronic records. Rates of 5-year reCoA, stent fractures, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were mid-term outcomes. The study included 274 patients (64% male and 36% female) with a median (interquartile range) age of 9 (6-12) years. Procedural success was achieved in 251 patients (91.6%). Procedural complications occurred in 4 patients (1.4%), consisting of stent migration in 1 (0.3%) and small non-expanding non-flow-limiting aortic wall injuries in 3 (1.1%). Major vascular access complications were observed in 18 patients (6.6%), acute limb ischemia in 8 (2.9%). In-hospital mortality occurred in 4 patients (1.4%). Five-year cumulative incidence rates of stent fractures, reCoA, and aortic aneurysmal/pseudoaneurysmal formation were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Of 73 reCoAs, 47 were treated with balloon angioplasty, and 15 underwent a second stent implantation. Five-year all-cause mortality occurred in 4/251 (1.6%) patients. Coarctoplasty with stents was safe and effective in our pediatric population during a 5-year follow-up despite a high rate of reCoA.
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Affiliation(s)
- Hojjat Mortezaeian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Elham Rezanejad
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Yeganeh Pasebani
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Raheleh Zamani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Yasaman Khalili
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Hamidreza Ghaemi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Farshad Jafari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Mahshad Sabri
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Jamal Moosavi
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Bahram Mohebbi
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Amir Abdi
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran
| | - Sara Montazeri Namin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran, 1995614331, Iran
| | - Parham Sadeghipour
- Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Medical and Research Institute, Tehran, Iran.
| | - Stephan Haulon
- Aortic Centre, Hopital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris-Saclay, Paris, France
| | - Alain Fraisse
- Paediatric Cardiology Services, Royal Brompton Hospital, London, SW3 6NP, UK
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Ahmadi A, Mansourian M, Sabri MR, Ghaderian M, Karimi R, Roustazadeh R. Follow-up outcomes and effectiveness of stent implantation for aortic coarctation: A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102513. [PMID: 38556144 DOI: 10.1016/j.cpcardiol.2024.102513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The authors aim to investigate the clinical implications of stent use for the management of CoA. METHODS All observational studies on stent implantation for the treatment of aortic coarctation and the relevant RCTs were systematically retrieved. Outcomes included the immediate success rate, pre- and post-stent gradient, survival, minor and major complications, restenosis, post-stent systolic blood pressure, and reintervention rate. The analysis was further stratified by CoA type, stent type, and the mean age of the patients. RESULTS Our meta-analysis incorporated 66 eligible studies involving 3,880 patients. The success rates for stent placement, defined as achieving post-treatment gradients of ≤20 mmHg and 10 mmHg, 0.96 (95% CI: 0.95 - 0.97; I2 = 59.83%) and 0.92 (95% CI: 0.89 - 0.95, I2 = 77.63%) respectively. The complication rates were quite low, with minor and major complication rates of 0.017 (95% CI: 0.013 - 0.021) and 0.007 (95% CI: 0.005 - 0.009), respectively. Unplanned reinterventions were required at a rate of 0.021 (95% CI: 0.015 - 0.026). At a mean follow-up of 2.9 years, 97% of the patients survived and 28% remained on antihypertensive therapy. While immediate effectiveness was consistent across age groups, complications were more prevalent in patients aged <20 years, and long-term efficacy was lower in those aged >20 years. Encouragingly, in neonates and infants, CoA stenting yielded results comparable to those observed in older children. CONCLUSION These findings underscore the overall favorable outcomes of stent placement for aortic coarctation, with considerations for age-related variations in complications and long-term efficacy.
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Affiliation(s)
- Alireza Ahmadi
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjan Mansourian
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad Reza Sabri
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Ghaderian
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Raheleh Karimi
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roshanak Roustazadeh
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany
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Abstract
Introduction Coarctation of the aorta in children under 3 months of age is usually treated surgically. However, there are clinical scenarios in which stenting of native or recurrent coarctation may become necessary in this age group. Case reports Four cases illustrate possible indications: left ventricular dysfunction increasing the operative risk, thrombus formation after coarctation surgery, patient size (i.e. in premature babies), and retrograde arch obstruction after hybrid palliation of hypoplastic left heart syndrome. In all babies, coarctation stenting was carried out successfully without complications. Conclusion Coarctation stenting can be carried out safely in small children. Usually, the stent has to be removed or redilated later. Results are encouraging. Electronic supplementary material The online version of this article (10.1007/s12471-020-01371-8) contains supplementary material, which is available to authorized users.
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Warmerdam EG, Krings GJ, Meijs TA, Franken AC, Driesen BW, Sieswerda GT, Meijboom FJ, Doevendans PAF, Molenschot MMC, Voskuil M. Safety and efficacy of stenting for aortic arch hypoplasia in patients with coarctation of the aorta. Neth Heart J 2019; 28:145-152. [PMID: 31784885 PMCID: PMC7052107 DOI: 10.1007/s12471-019-01353-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting. Methods A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit. Results Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p < 0.001). There were no major procedural complications. Mean systolic blood pressure decreased from 145 ± 16 mm Hg at baseline to 128 ± 9 mm Hg at latest follow-up (p = 0.014). Conclusion This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.
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Affiliation(s)
- E G Warmerdam
- University Medical Center Utrecht, Utrecht, The Netherlands.
| | - G J Krings
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - T A Meijs
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - A C Franken
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - B W Driesen
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - G T Sieswerda
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - F J Meijboom
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A F Doevendans
- University Medical Center Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
| | | | - M Voskuil
- University Medical Center Utrecht, Utrecht, The Netherlands
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Morrical BD, Anderson JH, Taggart NW. Exercise Capacity Before and After Stent Placement for Coarctation of the Aorta: A Single-Center Case Series. Pediatr Cardiol 2017; 38:1143-1147. [PMID: 28523342 DOI: 10.1007/s00246-017-1628-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
Over the last 15 years, stent placement has become a viable and safe alternative to surgical repair for native and recurrent coarctation of the aorta. Although patients with coarctation of the aorta often have lower exercise tolerance, there is no published data regarding the effect of coarctation stenting on exercise capacity. We aimed to determine the effect of coarctation stent placement on exercise capacity. We conducted a retrospective chart review of all patients who underwent stent placement for native or recurrent coarctation of the aorta at our institution from January 2000 to October 2012. We identified those patients who underwent exercise testing before and after stent placement. We compared measures of exercise capacity pre- and post-stent placement using paired t tests. Among 48 patients who underwent coarctation stenting, 7 (mean age = 40, range 21-65 years) were found to have isolated coarctation of the aorta and had the necessary pre- and post-stent exercise data. Only one patient had native coarctation of the aorta. The peak-to-peak systolic gradient improved by a mean of 26 mmHg (p < 0.02) after stent placement. Functional aerobic capacity (FAC) improved from a mean of 69-83% after stent placement (p < 0.03). Metabolic equivalents (METs) also improved significantly from a mean of 8.7 to 10.2 (p < 0.03). In our cohort, stent placement for relief of recurrent coarctation of the aorta resulted in a significant improvement in exercise capacity. This improvement may not be as significant in patients with milder coarctation of the aorta or those with complicating morbidities. Larger studies with more long-term follow-up are needed to better quantify this improvement and to define any lasting effect of this intervention on exercise tolerance.
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Affiliation(s)
| | - Jason H Anderson
- Department of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
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Abstract
Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.
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Salcher M, Mcguire A, Muthurangu V, Kelm M, Kuehne T, Naci H. Avoidable costs of stenting for aortic coarctation in the United Kingdom: an economic model. BMC Health Serv Res 2017; 17:258. [PMID: 28395657 PMCID: PMC5387244 DOI: 10.1186/s12913-017-2215-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/31/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Undesirable outcomes in health care are associated with patient harm and substantial excess costs. Coarctation of the aorta (CoA), one of the most common congenital heart diseases, can be repaired with stenting but requires monitoring and subsequent interventions to detect and treat disease recurrence and aortic wall injuries. Avoidable costs associated with stenting in patients with CoA are unknown. METHODS We developed an economic model to calculate potentially avoidable costs in stenting treatment of CoA in the United Kingdom over 5 years. We calculated baseline costs for the intervention and potentially avoidable complications and follow-up interventions and compared these to the costs in hypothetical scenarios with improved treatment effectiveness and complication rates. RESULTS Baseline costs were £16 688 ($25 182) per patient. Avoidable costs ranged from £137 ($207) per patient in a scenario assuming a 10% reduction in aortic wall injuries and reinterventions at follow-up, to £1627 ($2455) in a Best-case scenario with 100% treatment success and no complications. Overall costs in the Best-case scenario were 90.2% of overall costs at Baseline. Reintervention rate at follow-up was identified as most influential lever for overall costs. Probabilistic sensitivity analysis showed a considerable degree of uncertainty for avoidable costs with widely overlapping 95% confidence intervals. CONCLUSIONS Significant improvements in the treatment effectiveness and reductions in complication rates are required to realize discernible cost savings. Up to 10% of total baseline costs could be avoided in the best-case scenario. This highlights the need to pursue patient-specific treatment approaches which promise optimal outcomes.
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Affiliation(s)
- Maximilian Salcher
- LSE Health and Social Care, Cowdray House; London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Alistair Mcguire
- LSE Health and Social Care, Cowdray House; London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, Great Ormond Street Hospital, London, UK
| | - Marcus Kelm
- Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Huseyin Naci
- LSE Health and Social Care, Cowdray House; London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
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Yu Z, Wu S, Li C, Zou Y, Ma L. One stage surgical treatment of aortic valve disease and aortic coarctation with aortic bypass grafting through the diaphragm and aortic valve replacement. J Cardiothorac Surg 2015; 10:160. [PMID: 26555654 PMCID: PMC4640222 DOI: 10.1186/s13019-015-0338-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To validate ascending aorta-lower abdominal aorta bypass grafting treatment for patients with descending aortic coarctation and an aortic valve disease. METHODS The three patients in whom a descending atypical aortic coarctation was associated with an aortic valve disease were treated with one stage surgical treatment with aortic bypass grafting through the diaphragm and aortic valve replacement in our heart center. Operative technique consisted of performing ascending aorta-lower abdominal aorta bypass grafting through diaphragm muscle and implementing aortic valve replacement. The mean time for extracorporeal circulation and occluding clamp of aorta was recorded. Blood pressure data for pre- and post-operation was measured in the limbs. Computer-enhanced transvenous angiograms of pre- and post-operation were applied for detection of aortic stenosis. The other adverse events were noticed in outpatient service during a follow-up period. RESULTS The mean extracorporeal circulation time was 54 ± 11 min. The mean time for occluding clamp of aorta was 34 ± 6 min. An arterial pressure gradient was totally corrected after surgical treatment. Post-operation computer-enhanced transvenous angiograms showed the grafts to be open with a fluent flow. The patients had no gastrointestinal tract complications. No adverse event was noticed during a follow-up period in outpatient service. CONCLUSIONS Treatment of ascending aorta-lower abdominal aorta bypass is advisable for patients with descending aortic coarctation and an aortic valve disease.
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Affiliation(s)
- Zipu Yu
- Department of Cardiac Surgery, 1st Affiliated Hospital, Zhejiang University, 79 Qingchun road, Hangzhou, Zhejiang, China
| | - Shengjun Wu
- Department of Cardiac Surgery, 1st Affiliated Hospital, Zhejiang University, 79 Qingchun road, Hangzhou, Zhejiang, China
| | - Chengchen Li
- Department of Cardiac Surgery, 1st Affiliated Hospital, Zhejiang University, 79 Qingchun road, Hangzhou, Zhejiang, China
| | - Yu Zou
- Department of Cardiac Surgery, 1st Affiliated Hospital, Zhejiang University, 79 Qingchun road, Hangzhou, Zhejiang, China
| | - Liang Ma
- Department of Cardiac Surgery, 1st Affiliated Hospital, Zhejiang University, 79 Qingchun road, Hangzhou, Zhejiang, China.
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