Aortic aneurysms remain a significant source of morbidity and mortality after use of Dacron(®) patch aortoplasty to repair coarctation of the aorta: results from a single center

The Society of Thoracic Surgeons Clinical Practice Guidelines on the Management of Neonates and Infants With Coarctation

BACKGROUND

Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants.

METHODS

A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method.

RESULTS

For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E1, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques.

CONCLUSIONS

Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.

Strategies for Complex Reoperative Aortic Arch Reconstruction in Patients With Congenital Heart Disease

Aortic dilation is common in patients with congenital heart disease including those with a bicuspid aortic valve, connective tissue disease, coarctation of the aorta, and conotruncal defects. In addition, neo-aortic dilation has been described in patients after aortic reconstruction including the Norwood procedure, the arterial switch operation, and the Ross procedure. Although aortic catastrophe is rare in patients with congenital heart disease, common pathologic endpoints in these patients likely manifest with similar aortic tissue behavior. A lifelong care model with similar indications for surveillance and prophylactic repair to other more common aortopathies is therefore warranted. Still, reoperative aortic arch reconstruction in these patients is often a complex and high-risk endeavor, and in all cases, a tailored and adaptable plan ensuring adequate myocardial and cerebral protection with appropriate rescue measures is paramount. A surgical team taking on these challenging cases should possess an armamentarium of open, hybrid, and endovascular techniques which can be individualized to a patient's unique anatomy, surgical history, and concomitant lesions as well as the team's measured outcomes and experience.

Surgical and endovascular treatment of late post-coarctation repair aortic aneurysms: results from an international multicenter study

OBJECTIVE

Formation of post-aortic coarctation aneurysms (pCoAA) is well described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair dependent on clinical presentation, risk assessment, and anatomy. The aim of this study is to report early and mid-term results of open surgical and endovascular repair of pCoAA.

METHODS

This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The pre-, intra-, and postoperative data were recorded and analyzed.

RESULTS

A total of 74 patients [46 male, median age 44 years-old (IQR, 35-53)] underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation (CoA) at a median age of 11 years-old for the index procedure (IQR, 7-17). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. Median pCoAA diameter was 54 mm (IQR, 44-63). The median time from the CoA repair to the pCoAA diagnosis was 33 years (IQR, 25-40). A total of 33 patients had symptoms at presentation, including thoracic or back pain in eight. Open surgical repair was performed in 28 patients, including four frozen elephant trunk (FET) procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one FET and one endovascular). After a median follow-up of 50 months (IQR, 14-127), there was a total of seven reinterventions.

CONCLUSIONS

This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Since the median time between the coarctation repair and the aneurysm formation was over 30 years, life-long surveillance of these patients is warranted.

Midterm results of arch augmentation with autologous vascular patch in interrupted aortic arch

OBJECTIVES

Aortic arch reconstruction of interrupted aortic arch remains challenging, and subsequent problems, including arch and airway stenosis, may occur. Thus, we investigated midterm results of an augmentation technique using autologous vascular patch.

METHODS

This retrospective study included 24 patients who underwent arch reconstruction with an autologous vascular patch for interrupted aortic arch with biventricular physiology from 2006 to 2018. The median age and body weight at operation were 10 days (range 4-77 days) and 3 kg (range 2.5-5.1 kg), respectively. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from main pulmonary artery (n = 19), left subclavian artery (n = 3) or aberrant right subclavian artery (n = 1). One patient used patches from both the main pulmonary and left subclavian artery.

RESULTS

There was 1 early death due to right heart failure. All survivors were discharged 15 days (range 9-58 days) after surgery without residual arch stenosis. Late death occurred in 1 patient with Cri-du-chat syndrome and airway stenosis. Two reoperations and 1 intervention for arch stenosis were performed. The 1-, 5- and 10-year survival was 92%. Freedom from reoperation or intervention for arch stenosis was 86% 1, 5 and 10 years after surgery. No occurrence of arch aneurysm formation, left main bronchial stenosis and significant hypertension was found during a median follow-up period of 5.5 years (range 0.3-13.3 years).

CONCLUSIONS

Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in reasonable midterm outcomes.

Successful Ascending to Descending Aortic Bypass and Endovascular Embolisation of a Late Pseudoaneurysm Following Patch Aortoplasty for Coarctation of the Aorta

Introduction

A late aortic aneurysm at the site of previous open surgery for coarctation of the aorta (CoA) is a life threatening complication. Several strategies have been reported, however, these strategies have issues. This is the report of a case involving successful ascending to descending aortic bypass concomitant with endovascular embolisation for a pseudoaneurysm.

Report

The patient was a 23 year old man with a history of patch aortoplasty for coarctation of the aorta (CoA) via a left thoracotomy and patch closure of a ventricular septal defect. Enhanced computed tomography (CT) angiography performed in 2014 revealed a pseudoaneurysm at the site of the previous patch aortoplasty. CT also revealed a hypoplastic and severely kinked aortic arch that made it difficult to perform conventional thoracic endovascular aortic repair for this aneurysm. Therefore in order to prevent rupture, a combination of ascending to descending aortic bypass and endovascular embolisation using Amplatzer vascular plugs and coils was employed. Transection of the aortic arch and transposition of the left subclavian artery were performed to prevent antegrade flow into the aneurysm.

Discussion

The aneurysm was successfully excluded without complications. CT performed three years after the operation showed that the pseudoaneurysm had shrunk completely. Extra-anatomic bypass concomitant with endovascular embolisation for a late coarctation patched site aneurysm might be an alternative strategy that should be carefully considered in specific cases.

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A case of late coarctation patched site pseudoaneurysm is presented.

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Ascending to descending aortic bypass was performed successfully.

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The aneurysm was treated successfully by endovascular embolisation.

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Follow up computed tomography showed that the pseudoaneurysm had shrunk completely.

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This approach might be an alternative strategy that should be carefully considered.

Relapse of aortopulmonary window 41 years after patch closure

In this study, we describe a rare case of a 45-year-old man with a recurrence of aortopulmonary window (APW) 41 years after the initial patch closure for an APW at the age of 4. He presented with persistent cough and exertional dyspnoea. Imagings revealed a recurrence of APW, ascending aorta saccular aneurysm, and severe mitral and tricuspid regurgitation. Re-patch closure, ascending aortic replacement, and mitral and tricuspid annuloplasties were performed, followed by an uneventful postoperative course. The relapse of APW in the remote postoperative period is extremely rare.

Aortic Coarctation

Aortic coarctation is a discrete narrowing of the thoracic aorta. In addition to anatomic obstruction, it can be considered an aortopathy with abnormal vascular properties characterized by stiffness and impaired relaxation. There are surgical and transcatheter techniques to address the obstruction but, despite relief, patients with aortic coarctation are at risk for hypertension, aortic complications, and abnormalities with left ventricular performance. This review covers the etiology, pathophysiology, diagnosis, and management of adults with aortic coarctation, with emphasis on multimodality imaging characteristics and lifelong surveillance to identify long-term complications.

Efficacy and safety of dacron patch in surgical treatment of congenital disease by echocardiography

To evaluate the efficacy and safety of a new domestic dacron patch in the surgical treatment of congenital heart disease (CHD) with infective endocarditis (IE), a clinical controlled trial is conducted. 48 patients with CHD complicated with IE are selected and randomly divided into two groups. 26 patients in the experimental group are treated with a new domestic dacron patch, while 22 patients in the control group are treated with an imported cardiac polyester patch. By echocardiography, collecting chest X-ray, echocardiography and laboratory examination before and after operation, the residual shunt, cardiac function, liver function, renal function, coagulation function and other related indicators are observed after operation in the two groups, and the therapeutic effect and safety of the new dacron patch are evaluated. The results showed that there is no significant difference in C/T (cardiothoracic ratio), LAD (Left atrial diameter), LVSD (left ventricular end systolic diameter) and LVDD (left ventricular end diastolic diameter) between the two groups before operation, before discharge and 1, 3 and 6 months after discharge (P>0.05). The C/T, LAD and LVDD of the two groups decrease 6 months after operation, and the size of atrioventricle decreases significantly. There is a decreasing trend in the experimental group compared with the control group, but there is no significant difference (P>0.05). There are no significant differences in cardiac function classification, echocardiography, electrocardiogram, patch performance evaluation and blood compatibility between the two groups before operation and 6 months after discharge. CONCLUSION: The new domestic dacron patch has good clinical efficacy and safety.

Coarctation repair-redo challenges in the adults: what to do?

Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.

Case Report: An Innovative Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm following an Open Coarctation Repair

It was once postulated that open surgical repair of coarctation of the aorta during childhood patients was cured. However, long-term follow-up has been significant for late problems such as an aneurysm. The incidence of such aneurysm after open surgical coarctation repair is 11-24%. If such an aneurysm is left untreated, patients are at a high risk of morbidity and mortality. Prior to the endovascular era, patients would require a redo open repair which in itself is a highly morbid operation. Currently, thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical reprocedures in this context. However, TEVAR might be challenging due to the proximity of the pathology to supraaortic vessels and the ongoing presence of the coarctation. We are reporting a unique case of a 48-year-old male undergoing TEVAR due to aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm After Coarctation Operation

The incidence of aneurysm after open surgical repair of coarctation is 11% to 24%. If the condition is left untreated, fatal rupture may occur. Thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical repeated procedures in this context. However, TEVAR might be challenging because of the proximity of the pathologic condition to the supraaortic vessels and the ongoing presence of the coarctation. We report a unique case of a 48-year old man undergoing TEVAR because of aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

Augmentation of the Lesser Curvature With an Autologous Vascular Patch in Complex Aortic Coarctation and Interruption

BACKGROUND

Reconstruction of the aortic arch in patients with complex aortic coarctation or interruption continues to be a challenge because of early left main bronchial compression or recoarctation and late Gothic arch formation. We propose a modified arch reconstruction technique augmenting the lesser curvature with an autologous vascular patch, which can relieve tension on the anastomosis without a prosthetic material.

METHODS

We retrospectively reviewed 33 patients with coarctation and arch hypoplasia (n = 31) or arch interruption (n = 2) who underwent arch reconstruction with an autologous vascular patch from 2007 to 2012. Median age at the operation was 17 days (range, 5 to 200 days). Median body weight was 3.7 kg (range, 2.3 to 7.0 kg). Cardiopulmonary bypass was used for all operations. Median antegrade selective cerebral perfusion time was 35 minutes (range, 23 to 59 minutes). Combined intracardiac anomalies in 29 patients (88%) were corrected simultaneously. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from aortic isthmus (n = 25), pulmonary artery (n = 4), left subclavian artery (n = 2), aberrant right subclavian artery (n = 1), or distal arch (n = 1).

RESULTS

One patient (3%) died of acute respiratory distress syndrome. All survivors were discharged at 15 days (range, 7 to 58 days) postoperatively without neurologic complications or bronchial obstructions. Median follow-up was 24.8 months (range, 0.2 to 48.5 months). No recoarctation was observed during follow-up, and no patient needed reoperation.

CONCLUSIONS

Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in excellent midterm outcomes. Not only can a more natural shape of arch and less tension on the anastomosis be obtained, but complications, such as left main bronchial obstruction or recoarctation, can also be minimized. Long-term follow-up is needed to evaluate late development of recoarctation, hypertension, or aneurysm formation.

Percutaneous balloon angioplasty for severe native aortic coarctation in young infants less than 6 months: medium- to long-term follow-up

Background:

Although balloon angioplasty (BA) has been performed for more than 20 years, its use as a treatment for native coarctation of the aorta (CoA) during childhood, especially in young infants, remains controversial. This study aimed to assess the effects and potential role of percutaneous transcatheter BA for native CoA as an alternative therapy to surgical repair in young infants.

Methods:

The 37 patients aged from 6 days to 6 months with severe CoA in congestive heart failure or circulatory shock were admitted for BA. Patient's weight ranged from 2.4 to 6.1 kg. All 37 patients were experiencing cardiac dysfunction, and eight patients were in cardiac shock with severe metabolic acidosis. Eleven patients had an isolated CoA, whereas the others had a CoA associated with other cardiac malformations. Cardiac catheterization and aortic angiography were performed under general anesthesia with intubation. Transfemoral arterial approaches were used for the BA. The size of the balloon ranged from 3 mm × 20 mm to 8 mm × 20 mm, and a coronary artery balloon catheter was preferred over a regular peripheral vascular balloon catheter.

Results:

The femoral artery was successfully punctured in all but one patient, with that patient undergoing a carotid artery puncture. The systolic peak pressure gradient (PG) across the coarctation was 41.0 ± 16.0 mmHg (range 13–76 mmHg). The mean diameter of the narrowest coarctation site was 1.7 ± 0.6 mm (range 0.5–2.8 mm). All patients had successful dilation; the PG significantly decreased to 13.0 ± 11.0 mmHg (range 0–40 mmHg), and the diameter of coarctation significantly improved to 3.8 ± 0.9 mm (range 2.5–5.3 mm). No intraoperative complications occurred for any patients. However, in one case that underwent a carotid artery puncture, a giant aneurysm formed at the puncture site and required surgical repair. The following observations were made during the follow-up period from 6-month to 7-year: (1) The PG across the coarctation measured by echocardiography further decreased or remained stable in 31 cases. The remaining six patients, whose PGs gradually increased, required a second dilation. No patient required further surgery because of a CoA; (2) in two cases, an aortic aneurysm was found with an angiogram performed immediately postdilatation and disappeared at 18 and 12 months of age, respectively; (3) tricuspid regurgitation and pulmonary hypertension improved in all patients; (4) all patients were doing well and were asymptomatic.

Conclusions:

Percutaneous BA is a relatively safe and effective treatment for severe native CoA in young infants, and should be considered a valid alternative to surgery because of its good outcome and less trauma and fewer complications than surgery.

Endovascular repair of aortic coarctation pseudoaneurysm using an off-label "hourglass" stent-graft configuration

PURPOSE

To describe an endovascular technique for treating a pseudoaneurysm of the thoracic aorta using an off-label "hourglass" stent-graft configuration.

CASE REPORT

A 68-year-old patient with prior open thoracic aorta coarctation repair presented with recurrent coarctation and concurrent enlarging 6-cm bilobed pseudoaneurysm involving the previous anastomosis. There was significant discrepancy in the aortic diameter (measured from wall to wall) proximal to the coarctation (14 mm), at the narrowest segment (8 mm), and distally (23 mm). Endovascular repair included deployment of an inverted iliac limb proximally, followed by an inverted aortic converter distally, giving an "hourglass" configuration. There were no perioperative or stent-graft-related complications at 5-year follow-up. The aneurysm regressed from 61 to 25 mm.

CONCLUSION

The use of inverted stent-grafts can allow tapering and flaring to adapt to discrepant aortic diameters. This technique may be useful in select patients with prior coarctation repair who do not need excessive dilation of the narrow aortic segment.

Surgery for congenital diseases of the aorta

Congenital diseases of the aorta tend to be obstructive when they present early in life, and aneurysmal when they present later in life. The latter group also tends to be associated with connective tissue disorders and with repaired conotruncal lesions. The indications for intervention in the aneurysm group are still in evolution but are clearly age- and lesion-dependant. Disorders such as Loeys-Dietz syndrome and Turner syndrome may deserve aggressive prophylactic surgery, as well as Marfan syndrome to a lesser extent. The natural history of the dilated aorta after repair of congenital heart lesions is probably more benign than de novo aneurysms and therefore should be treated conservatively.

Thoracic aorta 3D hemodynamics in pediatric and young adult patients with bicuspid aortic valve

BACKGROUND

To evaluate the 3D hemodynamics in the thoracic aorta of pediatric and young adult bicuspid aortic valve (BAV) patients.

METHODS

4D flow MRI was performed in 30 pediatric and young adult BAV patients (age: 13.9 ± 4.4 (range: [3.4, 20.7]) years old, M:F = 17:13) as part of this Institutional Review Board-approved study. Nomogram-based aortic root Z-scores were calculated to assess aortic dilatation and degree of aortic stenosis (AS) severity was assessed on MRI. Data analysis included calculation of time-averaged systolic 3D wall shear stress (WSSsys ) along the entire aorta wall, and regional quantification of maximum and mean WSSsys and peak systolic velocity (velsys ) in the ascending aorta (AAo), arch, and descending aorta (DAo). The 4D flow MRI AAo velsys was also compared with echocardiography peak velocity measurements.

RESULTS

There was a positive correlation with both mean and max AAo WSSsys and peak AAo velsys (mean: r = 0.84, P < 0.001, max: r = 0.94, P < 0.001) and AS (mean: rS  = 0.43, P = 0.02, max: rS  = 0.70, P < 0.001). AAo peak velocity was significantly higher when measured with echo compared with 4D flow MRI (2.1 ± 0.98 m/s versus 1.27 ± 0.49 m/s, P < 0.001).

CONCLUSION

In pediatric and young adult patients with BAV, AS and peak ascending aorta velocity are associated with increased AAo WSS, while aortic dilation, age, and body surface area do not significantly impact AAo hemodynamics. Prospective studies are required to establish the role of WSS as a risk-stratification tool in these patients.

Late complication after repair of aortic coarctation

Background

Coarctation of the aorta is a congenital malformation that has long been considered completely correctable with appropriate surgery in childhood. However, with the aging of these patients, many late complications have been reported, and this notion must be reevaluated.

Methods

We retrospectively reviewed all patients who underwent reoperation between 1992 and 2012 in our adult cardiac surgery department following surgical correction of coarctation in childhood; 18 patients over 15-years old were included in the study.

Results

The median time from coarctation repair to reoperation was 25 years. Patients were reoperated on for several late complications: aortic valve disease secondary to bicuspid aortic valve, ascending aortic aneurysm, recoarctation, aortic arch hypoplasia, pseudoaneurysm, associated recoarctation and pseudoaneurysm, subvalvular aortic obstruction, and descending thoracic aortic aneurysm. One patient died due to an intraoperative complication. In the other cases, the surgical results were satisfactory at the 6-month follow-up. According to literature data, age at coarctation repair and surgical technique appear to be essential factors in late complications: older age and surgical repair with prosthesis interposition are associated with a higher rate of reintervention.

Conclusion

Patients who have undergone repair of aortic coarctation frequently remain asymptomatic for a long time. Late complications can be appropriately treated when diagnosed early. Consequently, all coarctation patients need careful lifelong follow-up, especially those with congenital aortic valve disease or surgery in childhood with interposition of prosthetic material.

Infiltration and sustenance of viability of cells by amphiphilic biosynthetic biodegradable hydrogels

Amphiphilic biosynthetic hydrogels comprising natural polysaccharide alginate (I) and synthetic polyester polypropylene fumarate (II) units were prepared by crosslinking the copolymer of I and II with calcium ion and vinyl monomers viz, 2-hydroxyethyl methacrylate (HEMA), methyl methacrylate (MMA), butyl methacrylate (BMA) and N,N'-methylene bisacrylamide (NMBA). Three fast degradable hydrogels, ALPF-MMA, ALPF-HEMA and ALPF-BMA and one slow degradable hydrogel ALPF-NMBA were prepared. These hydrogels are amphiphilic and able to hold sufficient amount of proteins on their surfaces. All these hydrogels are found to be hemocompatible, cytocompatible and genocompatible. ALPF-NMBA promotes infiltration of L929 fibroblasts and 3D growth of H9c2 cardiomyoblasts and long-term viability.

Noninvasive pressure difference mapping derived from 4D flow MRI in patients with unrepaired and repaired aortic coarctation

PURPOSE

To develop a method for computing and visualizing pressure differences derived from time-resolved velocity-encoded three-dimensional phase-contrast magnetic resonance imaging (4D flow MRI) and to compare pressure difference maps of patients with unrepaired and repaired aortic coarctation to young healthy volunteers.

METHODS

4D flow MRI data of four patients with aortic coarctation either before or after repair (mean age 17 years, age range 3-28, one female, three males) and four young healthy volunteers without history of cardiovascular disease (mean age 24 years, age range 20-27, one female, three males) was acquired using a 1.5-T clinical MR scanner. Image analysis was performed with in-house developed image processing software. Relative pressures were computed based on the Navier-Stokes equation.

RESULTS

A standardized method for intuitive visualization of pressure difference maps was developed and successfully applied to all included patients and volunteers. Young healthy volunteers exhibited smooth and regular distribution of relative pressures in the thoracic aorta at mid systole with very similar distribution in all analyzed volunteers. Patients demonstrated disturbed pressures compared to volunteers. Changes included a pressure drop at the aortic isthmus in all patients, increased relative pressures in the aortic arch in patients with residual narrowing after repair, and increased relative pressures in the descending aorta in a patient after patch aortoplasty.

CONCLUSIONS

Pressure difference maps derived from 4D flow MRI can depict alterations of spatial pressure distribution in patients with repaired and unrepaired aortic coarctation. The technique might allow identifying pathophysiological conditions underlying complications after aortic coarctation repair.

New-generation stent grafts for endovascular management of thoracic pseudoaneurysms after aortic coarctation repair

OBJECTIVE

Late thoracic aneurysms develop in 5% to 12% of patients having undergone open repair for coarctation of the aorta (CoA). We report our early results for thoracic endovascular aortic repair for pseudoaneurysms after CoA repair.

METHODS

From 2008 to 2013, data regarding demographics, aneurysm morphology, procedure, and follow-up were collected prospectively on all patients treated for pseudoaneurysms after CoA repair. Retrospective analysis of identified patients was then performed.

RESULTS

Thirteen patients (six men, seven women) were treated. Patients were a median age, 45 years (interquartile range (IQR), 39-56; range, 27-66 years, and the median time after CoA repair to aneurysm treatment was 34 years (IQR, 24-40 years). All patients had saccular pseudoaneurysms of the aortic arch, with a median aneurysm size of 4.1 cm (IQR, 3.4-5.1 cm). The left subclavian artery (LSCA) was involved in 10 patients and was occluded at presentation in three. Four patients had concurrent LSCA revascularization with carotid-subclavian bypass, one had aortic arch hybrid repair, and the LSCA was intentionally covered in two patients. Patients underwent thoracic endovascular aortic repair using the conformable TAG (6 of 13; W. L. Gore & Associates, Flagstaff, Ariz), Valiant device (4 of 13; Medtronic, Minneapolis, Minn), and a custom-made Relay endograft with LSCA scallop (4 of 13; Bolton Medical, Barcelona, Spain). Technical success was 100%, with satisfactory deployment of the stent grafts in all patients. There was no 30-day mortality, stroke, or paraplegia. Median follow-up was 15 months (IQR, 9-19 months; range, 1-67 months). Two type II endoleaks from an intercostal artery were managed conservatively, and one type Ib endoleak was treated successfully with distal stent extension.

CONCLUSIONS

In this cohort, new-generation stent grafts have good early clinical and radiologic outcomes, avoiding the need for redo open surgery. Management of the LSCA can be tailored to individual patients with new stent graft technology. Long-term follow-up of these patients is crucial to understanding whether endovascular management of this cohort is acceptable.

Screening for aortic aneurysm after treatment of coarctation

Isolated coarctation of the aorta (CoA) occurs in 6-8 % of patients with congenital heart disease. After successful relief of obstruction, patients remain at risk for aortic aneurysm formation at the site of the repair. We sought to determine the diagnostic utility of echocardiography compared with advanced arch imaging (AAI) in diagnosing aortic aneurysms in pediatric patients after CoA repair. The Congenital Heart Databases from 1996 and 2009 were reviewed. All patients treated for CoA who had AAI defined by cardiac magnetic resonance imaging (MRI), computed tomography (CT), or catheterization were identified. Data collected included the following: type, timing, and number of interventions, presence and time to aneurysm diagnosis, and mortality. Patients were subdivided into surgical and catheterization groups for analysis. Seven hundred and fifty-nine patients underwent treatment for CoA during the study period. Three hundred and ninety-nine patients had at least one AAI. Aneurysms were diagnosed by AAI in 28 of 399 patients at a mean of 10 ± 8.4 years after treatment. Echocardiography reports were available for 380 of 399 patients with AAI. The sensitivity of echocardiography for detecting aneurysms was 24 %. The prevalence of aneurysms was significantly greater in the catheterization group (p < 0.05) compared with the surgery group. Aneurysm was also diagnosed earlier in the catheterization group compared with the surgery group (p = 0.02). Multivariate analysis showed a significantly increased risk of aneurysm diagnosis in patients in the catheterization subgroup and in patients requiring more than three procedures. Aortic aneurysms continue to be an important complication after CoA repair. Although serial echocardiograms are the test of choice for following-up most congenital cardiac lesions in pediatrics, our data show that echocardiography is inadequate for the detection of aneurysms after CoA repair. Because the time to aneurysm diagnosis was shorter and the risk greater in the catheterization group (particularly for patients requiring more than one procedure), surveillance with cardiac MRI or CT should begin earlier in these patients.