Stent angioplasty: an effective alternative in selected infants with critical native aortic coarctation

Treatment of a severe distal thoracic and abdominal coarctation with cutting balloon and stent implantation in an infant: From fetal diagnosis to adolescence

Background and Aims

Abdominal coarctations are rare. Surgical treatment is difficult and requires re‐interventions to adjust the graft material to patient growth. We report effective treatment by interventional catheterization in an infant with the concern to allow adjustment for growth and prevention of vessel damage.

Methods and Results

After the diagnosis of abdominal coarctation at 27 weeks of gestation, an infant developed hypertension (170/70 mmHg) at 3 months of age despite medical therapy. Angio CT confirmed a 2 mm diameter, 2.3‐cm‐long coarctation of the descending aorta. At 4 months, a dilatation was performed using a 3 mm cutting balloon and a 5 mm Opta® balloon, Cordis®. Two noncovered Palmaz® Genesis™ XD PG1910P stents were required to keep the aortic lumen open. At 15 months, an Adventa™ V12 vascular 12 × 61 mm long covered stent was implanted to exclude an aneurysm which developed between the two stents. At 3 and 9.5 years, the stents were further dilated with a high‐pressure balloon to reach 11 mm aortic diameter with no residual pressure gradient, and normal blood pressure.

Conclusions

The use of cutting balloons and stent implantation is an effective way to relieve severe obstruction in middle aortic syndrome in neonates. The technical issues encountered were the need for a low profile sheath and material to avoid femoral artery damage, and the need to use stents that can be further expanded to adult size.

Our first experience in stenting of coarctation of aorta in infants and small children; A case series study

BACKGROUND

One of the congenital heart defects which can cause severe cardiac symptoms and cardiac failure in early childhood and neonatal duration is coarctation of aorta. Balloon angioplasty or surgical approach could be done for management of these defects. This study aimed to evaluate the efficacy and safety of coarctation stenting to improve the condition of these patients.

METHODS

Five patients with severe coarctation of aorta participated in this study. Balloon angioplasty performed for these patients initially. Each of five patients had a gradient decline after the initial balloon angioplasty, and againing gradients increased during the follow-up; then, they were treated by implanting a stent. We used Cook Formula stents for these patients.

RESULTS

The pressure gradient decreased in all 5 patients with maximum and minimum reduction of 55 and 35 mmHg; and we had not severe complication during or after the procedure and during the follow-up period.

CONCLUSION

Performing a stent in selected small children and infants that have sever and symptomatic coarctation of aorta can be effective and safe in improving patients' clinical state, and preventing surgery.

Stent Angioplasty for Critical Native Aortic Coarctation in Three Infants: Up to 15-Year Follow-Up Without Surgical Intervention and Review of the Literature

Management of neonatal native coarctation is debated till now. Surgical therapy remains an option but may be unwarranted in critically sick infants with complex lesions. Balloon dilatation has been employed but with early re-stenosis. Stent angioplasty has also been used but as a bridge towards definitive surgical therapy. Four critically sick infants with complex coarctation and additional co-morbidity factors underwent primary stent therapy as surgical intervention was denied. One patient had died earlier due to reasons unrelated to the procedure. Three survivors underwent multiple dilatations of primary stents as indicated. One of the three survivors did not require any further dilatation after the age of 5 years and remained stable till the time of reporting. High-pressure Cheatham Platinum stents were implanted inside the primary stents in two infants, who developed re-stenosis due to somatic growth. These stents were further balloon dilated at high atmospheric pressure. Femoral arteries in both of them were blocked but were re-canalized after balloon dilatation in one and stent angioplasty in the other. After a follow-up of about 15 years, all of them have been doing fine with acceptable Doppler gradients. They were normotensive and on no cardiac medications. It can be concluded that, though surgical repair remains a standard of care, stent angioplasty in selected infants with complex lesions is feasible and effective. Multiple dilatations can be performed without added risk of stent migration. Bio-absorbable and growth stents hold a promise for future use in such situations.

Middle aortic syndrome--an 8-year story of pills, pretty balloons and struts

BACKGROUND

Middle aortic syndrome (MAS) is an uncommon cause of hypertension in children. The management of hypertension secondary to MAS frequently requires several anti-hypertensive medications along with endovascular and often surgical intervention.

CASE-DIAGNOSIS/TREATMENT

A 9-year-old boy presented with headaches and vomiting and was diagnosed with severe hypertension secondary to idiopathic MAS affecting a long segment of the abdominal aorta and left renal artery stenosis. Over the following 8 years his hypertension was successfully managed initially with percutaneous transluminal balloon angioplasty (PTA) of his left renal artery, followed by balloon dilatation of his abdominal aortic narrowing. He subsequently underwent abdominal aortic stent placement following failed repeat aortic balloon dilatation. Aged 17 years and 6 months he is now on a single anti-hypertensive agent with normal renal function and no evidence of target organ damage.

CONCLUSION

In selected cases, MAS may be managed with PTA and stent placement with good long-term outcomes. Limited data on the use of PTA and stent insertion in children means that a structured approach to the management of refractory hypertension secondary to MAS remains elusive.

Current state of interventional cardiology in congenital heart disease

Congenital interventional cardiology seeks to provide alternative percutaneous solutions to congenital cardiac problems in preference to more traditional surgical approaches. Simpler procedures have been refined and are now achievable in smaller children and infants. More complex procedures are increasingly recognised as superior to surgical alternatives, though most patients with complex disease inevitably undergo combinations of interventional, surgical and joint or hybrid procedures. This review seeks to highlight recent advances in these techniques of most interest to the readership of this journal.

Effect of interventional stent treatment of native and recurrent coarctation of aorta on blood pressure

The aim of this study was to describe the clinical impact of management of coarctation of the aorta by transcatheter stent placement in the context of longer term management of systemic hypertension. In the long term, poor outlook associated with untreated coarctation of the aorta is likely to relate to uncontrolled systemic hypertension. Transcatheter stent placement to treat native and recurrent coarctation of the aorta is an established therapy in adolescents and adults. There remains confusion about longer term outcomes, particularly the relation between procedural success and improvement in blood pressure (BP) control. Improvement in lifelong systemic BP control after transcatheter stent placement remains unproved. Forty patients underwent transcatheter stent placement over a 10-year period (2001 to 2010) at the Yorkshire Heart Centre. The average age at the time of procedure was 25 years (range 14 to 57). There was a reduction in peak systolic gradient across the coarcted segment from 25 to <10 mm Hg in 35 of 39 patients. After stent placement, there was a significant improvement in systolic BP control at early and later follow-up (mean 155 mm Hg before the procedure and 134 mm Hg at 2.81-year follow-up, p <0.0001). There was 1 early procedural adverse event (stent embolization) and 1 late adverse event (lower limb claudication). In conclusion, transcatheter stent placement for the management of aortic coarctation is associated with a reduction in systolic BP that is maintained over the medium term. A significant minority of patients remain significantly hypertensive, and the best management strategy for this group of patients remains unclear.

Palliative stent implantation for coarctation in neonates and young infants

Background:

In selected neonates and infants, primary palliative stent implantation may be indicated for coarctation of the aorta. We describe our experience with this approach in five consecutive patients.

Methods:

Five neonates and infants (age range 6 to 68 days, gestation 33 to 38 weeks, weight range at procedure of between 1650 to 4000 g) underwent palliative stent implantation as primary therapy for coarctation of the aorta. Indications for primary stent implantation were varied. All procedures were performed by elective surgical cut down of the axillary artery. Standard coronary stents (diameter 4.5 to 5 mm, length 12 to 16 mm) were delivered via a 4F sheath. The axillary artery was repaired after removal of the sheath.

Results:

All procedures were acutely successful, and without procedural complications. All patients survived to hospital discharge. Four patients have subsequently undergone elective stent removal and surgical repair of the arch, at between 38 and 83 days following stent implantation. Complete stent removal was achieved in three patients. Over a follow-up ranging between 8 weeks and 36 months, none of the patients has had any further complications.

Conclusions:

This palliative approach is warranted in carefully selected patients. Long-term follow-up is required.

Emergency balloon dilation or stenting of critical coarctation of aorta in newborns and infants: An effective interim palliation

Background:

Management of native uncomplicated coarctation in neonates remains controversial with current evidence favoring surgery. The logistics of organizing surgical repair at short notice in sick infants with critical coarctation can be challenging.

Methods and Results:

We reviewed data of 10 infants (mean age of 2.9 ±1.6 weeks) who underwent catheter intervention for severe coarctation and left ventricular (LV) dysfunction between July 2003 and August 2007. Additional cardiac lesions were present in 7. Mean systolic gradient declined from 51±12 mm Hg to 8.7±6.7 mm Hg after dilation. The coarctation segment was stented in five patients. Procedural success was achieved in all patients with no mortality. Complications included brief cardiopulmonary arrest (n =1), sepsis (n = 1) and temporary pulse loss (n = 2). LV dysfunction improved in all patients. Average ICU stay was 5±3.4 days and hospital stay was 6.5±3.4 days. On follow-up (14.1±10.5 months), all developed restenosis after median period of 12 weeks (range four to 28 weeks). Three (two with stents) underwent elective coarctation repair, two underwent ventricular septal defect (VSD) closure and coarctation repair and one underwent pulmonary artery (PA) banding. Two patients who developed restenosis on follow-up were advised surgery, but did not report. Two (one with stent) underwent redilatation and are being followed with no significant residual gradients.

Conclusion:

Balloon dilation ± stenting is an effective interim palliation for infants and newborns with critical coarctation and LV dysfunction. Restenosis is inevitable and requires to be addressed.

Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents

AIMS

To assess the efficacy, safety, and long-term results of the balloon angioplasty of recoarctation.

METHODS AND RESULTS

The angioplasty was performed in 99 consecutive patients aged 36 days to 32.6 years (median 268 days). Recoarctation to descending aorta diameter ratio increased from 0.44 (0.35/0.50) to 0.66 (0.57/0.77), P < 0.001. Systolic gradient was reduced from 34.0 (26.0/44.75) to 15.0 (8.25/27.0) mmHg, P < 0.001. In seven patients (7.1%) the procedure was ineffective. One patient (1%) with heart failure died within 24 h after a successful angioplasty and in another (1%) an intimal abruption necessitated surgical revision. The follow-up ranged up to 20.7 years (median 8.1 years). Actuarial probability of survival 20.7 years after the procedure was 0.91, and of reintervention-free survival was 0.44. Older age at the angioplasty was associated with a higher incidence of reinterventions (hazard ratio 1.057; 95% confidence interval 1.012-1.103; P = 0.010). The type of surgery and the recoarctation anatomy did not influence the outcome. In 69 patients aneurysm formation was studied by high-sensitive methods with only one positive finding per 462 patient-years.

CONCLUSION

Angioplasty is safe and effective regardless of the type of surgery used and the recoarctation anatomy. Older age at the angioplasty is associated with a higher incidence of reinterventions.