Treatment of aortic coarctation in adolescence

Anterograde stent implantation for treatment of recurrent coarctation after Norwood operation

Although balloon angioplasty (BA) has become the standard therapy for recurrent aortic arch obstruction, pressure gradient relief is often not complete, with a high incidence of restenosis after BA. We report our experience with anterograde stent implantation for treatment of recurrent arch obstruction in patients with hypoplastic left heart syndrome after Norwood operation. Between March 2003 and January 2006, seven patients with the Norwood procedure required BA. The average weight was 6.3 kg (range, 4.4-9.8 kg). Four patients had undergone prior BA. For the purpose of relieving aortic arch obstruction, we used five Palmaz Genesis (PG) XD stents, and for palliative purposes we used one PG 124P stent and one Jostent, 6-12 mm. The average time after Norwood stage I was 177 days (range, 56-365 days). In six of seven patients the procedure was performed antegradely from the femoral vein. In all patients the procedure was effective. The peak systolic gradient fell from 29 mm Hg (range, 5-70 mm Hg) to 3 mm Hg (range, 0-10 mm Hg). There were no complications. No aneurysm, stent dislocation, or severe bleeding was observed. In two of seven patients three growth-related redilatations were performed. We conclude that implantation of stents at the site of recurrent coarctation after Norwood operation shows excellent gradient relief. To reduce the risk of vascular complications due to arterial access in this small group of patients, the procedure can be done safely anterogradely.

Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms

We report our experience with implantation of stents for treatment of recurrent and native aortic coarctation in children weighing less than 20 kilograms. We treated 9 such patients between March, 2003, and January, 2006. In 2 patients, the coarctation had not previously been treated, while in 7 it had recurred after surgery. The patients had a median weight of 14 kilograms, with a range from 5.5 to 19 kilograms. Balloon dilation was needed in 1 patient before the stent was implanted. We used Palmaz Genesis XD stents in 7 patients, these having lengths from 19 to 29 millimetres, 1 Palmaz Genesis 124P stent, and 1 peripheral JoStent with a diameter of 6 to 12 millimetres. Implantation was effective in all patients. Immediately after implantation, the mean peak systolic gradient decreased from 30 millimetres of mercury, the range having been 15 to 50 mm, to 3 millimetres of mercury, with the final range from zero to 10 mm. There were no complications, with no observations of aneurysms, dissections, or dislocated stents. In 1 patient, the peripheral pulse was weak secondary to arterial access, but treatment with Heparin led to complete resolution. It was necessary to re-dilate the stent in another patient, while 2 others are scheduled for redilation because of growth-related restenosis. Our findings suggest that implantation of stents can produce excellent relief of the gradient produced by recurrent or native coarctation. The process is safe and effective in patients weighing less than 20 kilograms.