Outcomes of Thoracic Endovascular Aortic Repair in Adult Aortic Coarctation Patients

Abstract

Although aortic coarctation is most commonly seen in pediatric patients, adults can present with late sequelae of untreated coarctation or complications of the index repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis is to describe our experience with management of adult coarctation patients treated with TEVAR. A retrospective review was completed of a prospectively maintained endovascular aortic registry at a university hospital. All patients treated for primary coarctation or for late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation/anastomotic stenosis related to index open coarctation repair) were included. Patient demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were abstracted. Computed tomographic centerline assessments of endograft morphology were also completed to delineate stent anatomy at the site of coarctation. Survival was estimated using Kaplan-Meier life tables. A total of 21 patients were identified (median age = 46 years [range, 33-71]; 67% male [n = 14]). Nine patients (43%) were treated for symptomatic primary (n = 6) or recurrent coarctation (n = 3). Other indications included degenerative thoracic aneurysm (n = 6), pseudoaneurysm (n = 4), and dissection (n = 2). Zone 1 or 2 landings were employed in 15 patients (zone 2, n = 13; zone 1, n = 2). Additional procedure-related data is depicted in the Table. No 30-day mortality events occurred, and two patients (10%) experienced a postoperative complication (nondisabling stroke, n = 2). At a median clinical follow-up time of 8 months (range, 1-106), three endoleaks were detected, all of which were type 2 related to patent left subclavian (n = 2) or aberrant subclavian arteries (n = 1). Four patients (19%) underwent reintervention (median time, 7 months [range, 2-12]), and three out of four of these were subclavian artery embolizations, whereas one was for aortic root replacement because of pre-existing bicuspid aortic valve with concomitant ascending aortic aneurysm. In patients with available computed tomography imaging (n = 6 of 9 primary/recurrent coarctation subjects), nominal stent diameters at the site of coarctation were effectively achieved within these patients (range, -0.4 to -1.2 mm of desired final stent diameter). One- and 3-year survival is estimated to be 95 ± 5% (Fig). One late death occurred related to complications from pre-existing congenital heart disease. Adult patients with aortic coarctation can be treated safely with TEVAR. The annular constriction of an aortic coarctation can be successfully dilated by the self-expanding stent graft. Greater patient numbers and longer term follow-up are needed to further define the role of TEVAR in the management adult patients with complications of aortic coarctation.TableProcedure-related variables of adult aortic coarctation patients undergoing TEVAR (thoracic endovascular aortic repair)Feature, N = 21No. (%)Preoperative spinal drain8 (38%)Intraoperative adjuncta10 (47%) -Left carotid-subclavian bypass/transposition7 -Left subclavian artery embolization6 -Left carotid stent1 -Right carotid subclavian bypass/transposition2 -Right atrial inflow balloon occlusion1 -Right subclavian artery embolization1Device type Medtronic17 (81%)-Valiant11-Talent6 Cook TX23 (14%) Gore TAG1 (5%)Operative time, minutesb139 [70, 200]Fluoroscopy time, minutesb15 [12, 20]Contrast exposure, mLb95 [40, 130]Estimated blood loss, mLb150 [100, 200]aSome patients received multiple adjuncts.bMedian [interquartile range]. Open table in a new tab