Percutaneous treatment of native aortic coarctation in adults

The transradial approach during transcatheter structural heart disease interventions: a review

AIMS

To review the safety and feasibility of a transradial (TR) approach during transcatheter structural or congenital heart disease interventions when utilized as either as a primary or secondary arterial access site.

METHODS AND RESULTS

Studies and case reports published between 2002 and 2014 utilizing the TR access during transcatheter structural and congenital heart disease interventions during alcohol septal ablation (ASA), ventricular septal defect (VSD), renal denervation (RD), paravalvular leak (PVL) closure, transcatheter aortic valve implantation (TAVI, secondary access) and endovascular repair of aortic coarctation (ERAC, secondary access) were evaluated. Access-site (femoral vs. TR) vascular and bleeding complications were assessed. Femoral access complications ranged from 0.16% to 40%, with an overall incidence of 2.2% (56/2521). There were 18 reports or studies specifically evaluating the utility of TR access in the context of transcatheter structural heart disease interventions (ASA: 3; VSD: 1; RD: 3; PVL closure: 1; TAVI: 7, ERAC: 3). The use of TR access either as primary or secondary access site was feasible and allowed the completion of the procedure in all cases. The overall incidence of access-site complications following a TR approach was 0.5% (2/406 patients), with no major vascular or bleeding complications.

CONCLUSIONS

A TR approach during transcatheter structural heart disease interventions appears to be a safe, effective means of delivering high procedural success accompanied by lower bleeding complications compared with the transfemoral approach.

Coarctoplasty and Stenting in a Case of Ventricular Septal Defect With Eisenmenger's Syndrome: A Clinical Dilemma

Coarctoplasty with stenting is often an effective strategy in cases of recoarctation following surgical repair. The potential benefit of coarctoplasty in a patient with Eisenmenger's syndrome is unknown. We describe the case of a 21-year-old male who presented with claudication of lower limbs. He was known to have congenital heart disease, consisting of ventricular septal defect, patent ductus arteriosus (PDA), and coarctation of the aorta. Coarctation repair and PDA ligation had been done at two months of age. At the time of presentation for evaluation of claudication, echocardiography revealed severe coarctation and evidence of Eisenmenger's syndrome. This patient subsequently underwent balloon angioplasty and stenting of coarctation without any increase in cyanosis.

Results of using cardiopulmonary bypass for spinal cord protection during surgical repair of complex aortic coarctation

BACKGROUND

The aim of this study was to evaluate the surgical treatment of complex aortic coarctation using partial cardiopulmonary bypass to increase the spinal cord protection.

METHODS

A total of 15 patients (age range from 7 to 48 years) underwent coarctation repair through a left posterolateral thoracotomy with cardiopulmonary bypass. Cannulation was performed via the descending aorta and the main pulmonary artery. In all, six surgeries were performed under hypothermic circulatory arrest and nine repairs were performed under mild hypothermia. The clinical outcome regarding the development of restenosis, as well as major neurologic complication, was studied.

RESULTS

There was no mortality. None of the patients developed paraplegia. Of the 15 patients, two developed a recurrent stenosis at the proximal anastomosis between the aortic arch and the aortic prothesis at a mean follow-up of 5.5 years. In the remaining 13 patients, echocardiography and magnetic resonance imaging showed no evidence of a significant gradient.

CONCLUSION

Complex aortic coarctation without hypoplasia of the proximal aortic arch and intra-cardiac anomalies can be repaired with low mortality and neurologic morbidity via a left thoracotomy using cardiopulmonary bypass. The use of cardiopulmonary bypass goes along with a low risk of spinal cord and lower body ischaemia and provides a sufficient amount of time for the anastomoses.