Stenting Of Aortic Coarctation Research Articles

Dual Arterial Access for Stenting of Aortic Coarctation in Patients with Near-Total Descending Aortic Interruption.

Endovascular stenting is a recognized treatment strategy for the treatment of coarctation of aorta (COA) in adults. The aortic coarctation is usually crossed retrogradely from the descending aorta via the femoral approach. We report three patients who had near-total descending aortic interruption and underwent successful stenting of severe COA using a combined radial/brachial and femoral approach due to difficulty in crossing the lesion retrogradely via a femoral approach. There were no procedural complications and no adverse events during 6 months of follow-up.

Patient-Specific Simulations in Interventional Cardiology Practice: Early Results From a Clinical/Engineering Center

Patient-specific models have been recently applied to investigate a wide range of cardiovascular problems, including cardiac mechanics, hemodynamic conditions, and structural interaction with devices [1]. The development of dedicated computational tools, which combined the advances in the field of image elaboration, finite element (FE), and computational fluid dynamic (CFD) analyses, has greatly supported not only the understanding of human physiology and pathology but also the improvement of specific interventions by taking into account realistic conditions [2,3]. However, the translation of these technologies into clinical applications is still a major challenge for the engineering modeling community [4].Over the last decade, our engineering group, which is part of the Cardiorespiratory Unit in the main UK children hospital, has been involved in the development of patient-specific models to support the development of the percutaneous pulmonary valve implantation (PPVI) procedure [5,6]. This experience allowed the creation of a library with over 600 anatomical models of cardiovascular structures and 24 devices for a variety of cardiovascular interventions. In this context, there was an increasing clinical demand to extend the use of such models in planning interventions, especially in complex cases of congenital heart disease.In this study, we report the early results of the translations of patient-specific computational simulations into clinical practice to predict outcomes of percutaneous interventions.Six patients who were referred to our Center for PPVI (n = 4) and stenting of aortic coarctation (CoA, n = 2) were included in this study. Image data conventionally acquired for patients' clinical assessment, including computed tomography and magnetic resonance imaging, were postprocessed to reconstruct the three-dimensional anatomy of the site of cardiovascular structures. For each case, patient-specific computational analyses were set up in order to simulate peri- and postoperative scenarios using different devices, which vary in terms of size and shape, from our library of available device models. In particular, following morphological measurements, FE analyses simulated the implantation phases of selected devices and their interaction with the individual implantation site, while CFD analyses were performed to investigate the hemodynamics before and after the intervention. Results of patient-specific models were presented and discussed during the multidisciplinary cardiac meeting in our unit to assess the feasibility of the intervention. Finally, clinical outcomes were compared with the model predictions.The simulations concerning the patients referred for PPVI indicated feasibility in all cases and outlined the best-fitting device for each individual following analyses of the interaction between the available stents and the implantation sites (Figs. 1(a)–1(c)). Clinical procedures provided successful outcomes and a good agreement with the predictions in three cases. One PPVI was not performed following balloon sizing because, during the catheterism, a highly distensible implantation site was felt not suitable for the stability of the stent.The simulations of stenting of the first CoA case provided information on the optimal size of a covered stent, which was identified as best solution to restore physiological flow conditions (Fig. 1(d)). This prediction was in excellent agreement with the clinical outcomes. In the second CoA case, a thoracic endovascular graft was suggested. This intervention is currently planned to avoid surgery in this patient.This study reports the early results of a prospective study, which aims to translate patient-specific models into clinical practice. The first results are promising in terms of reliability of the simulations, response time, and usefulness in clinical practice. However, future studies will need to include more realistic data about mechanical characterization of specific patients and possibly further reduce the computational costs. The translation of these technologies is crucial, as it can limit the procedural risks of currently available devices and support the development of new devices that are morphologically and functionally suitable for each patient.

Infolding of covered stents used for aortic coarctation: Report of two cases

Covered stents have been used for the treatment of aortic coarctation to protect the arterial wall during dilation. Early results have shown them to be safe and effective. We report two cases of infolding of the proximal edge of a covered aortic coarctation stent. Management required implantation of a second stent. Poor stent apposition to the vessel wall and/or recoil may allow conditions for these events to occur.

Multimodality 3D‐roadmap for cardiovascular interventions in congenital heart disease—A single‐center, retrospective analysis of 78 cases

Modern fluoroscopic angiography systems permit rendering of three-dimensional volumetric data sets using rotational angiography (3D-RA). Along with magnetic resonance imaging (MRI) or multi-detector-row computed tomography (MDCT) data sets, they can be fused with live fluoroscopy images for roadmapping during therapeutic procedures, but the value of multimodality fused data sets has not been clarified. In a pediatric cardiac catheterization laboratory, we analyzed 78 interventional cardiovascular procedures in which 3D models of 3D-RA, MRI, or MDCT were used for 3D-guidance. Accuracy of 2D-3D registration as well as overall procedural benefit was independently rated by two pediatric interventionalists. Fluoroscopy time, radiation dose, and contrast dye consumption were evaluated and, grouping a subgroup analysis, the parameters were compared between patients who underwent stenting of aortic coarctation with and without 3D-roadmapping. 3D-guiding was used in 78 cases, 75 of these cases were with accurate 2D-3D registration. 3D-roadmapping was rated superior to conventional biplane imaging in 74 cases. 3D-guidance was used in 64 cases to define the ideal C-arm angulation and in 60 cases for accurate device positioning. Median dose-area product in the total investigation was 706.3 μGym(2) (104.8-7249.7 μGym(2) ), 3.3 ml/kg (0.9-13.7 ml/kg) of contrast dye was used, and total fluoroscopy time was 14.5 min (2.9-68.1 min). Fluoroscopy time for 3D-guided stenting of aortic coarctation is significantly lower (8.35 versus 10.2 min; P = 0.04). 3D-image fusion with live fluoroscopy can be applied successfully in catheter-based interventions of congenital heart disease. 3D-guidance facilitates catheter manipulations and interventions, allows preselection of ideal projection angles, reduces fluoroscopic time and the number of control angiographies.

A Case of Successful Bare Metal Stenting for Aortic Coarctation in an Adult

Aortic coarctation is a correctable hypertensive disease. For safety reasons and due to the invasiveness of surgical techniques, percutaneous interventions have become drastically more popular in recent times. In elderly patients with aortic coarctation who are at risk of an aortic wall aneurysm and rupture, covered stents are preferred but in younger patients, bare metal stenting may be sufficient for long-term safety. Herein we present a 47-year-old typical aortic coarctation patient who was successfully treated with a bare metal stent.

Quantification of temporal, procedural, and hardware‐related factors influencing radiation exposure during pediatric cardiac catheterization

To quantify the impact of relocation to a purpose built pediatric cardiac catheterization laboratory, on patient radiation dose and fluoroscopy time. To provide guide values for radiation exposure during common structural interventions. A retrospective review of common structural cardiac interventions performed over 10-years. The era comprised two 5-year periods before and after relocation using different catheter laboratories. Multivariable analysis adjusted for the following variables: era (pre- and post-move), year, operator seniority, patient age, procedure type. A quaternary referral congenital cardiac centre. All patients <18 yrs (n = 756) in whom one of 6 common structural interventions were undertaken between 2000 and 2009. Radiation dose and fluoroscopy time. The move to the new laboratory (latter era) was associated with a dramatic reduction in multivariable-adjusted radiation dose, ranging from 64% (aortic coarctation stenting) to 87% (patent arterial duct closure). There was also a year upon year increase in radiation dose of 5.2% [95% confidence interval (CI): 0.6-10.0%], which persisted after the relocation. However, this was associated with a 5.1% yearly decrease in fluoroscopy time (95% CI: -7.9 to -2.2%). Use of state-of-the-art catheter equipment is associated with a dramatic reduction in radiation exposure. However, the surprising finding of year upon year increase in exposure (despite the new equipment) combined with decreased fluoroscopy time suggests a temporal decrease in hardware efficiency. This has major implications for hardware replacement.

Hybrid stenting of aortic coarctation in very low birth weight premature infant

A very low birth weight infant with severe aortic coarctation developed progressive left ventricular dysfunction and pulmonary overflow with hemorrhage, while receiving prostaglandins. To avoid morbidity from conventional surgery or percutaneous intervention, a two-step strategy was performed at a weight of 970 g. First vascular access was obtained through sternotomy: a 3/8 mm coronary stent was deployed through a 4 French sheath in the ascending aorta; the arterial duct was clipped. At the age of 5 months, the stent was removed and the aortic arch reconstructed with an end-to-end anastomosis through lateral thoracotomy. This strategy was not associated with morbidity typical for premature infants with congenital heart disease.

Stenting of aortic coarctation: Technical considerations and procedural outcomes

Coarctation of the aorta is one of the more common congenital cardiac lesions. While transcatheter approaches, such as balloon angioplasty and stent implantation are often considered the primary therapeutic strategies for most patients with recoarctation, there is still considerable controversy with regard to the best therapeutic strategy for older patients with primary coarctation, mainly related to the lack of long-term outcome data. This article will highlight technical and procedural considerations for stent implantation for aortic coarctation.

Zabiegi stentowania natywnej koarktacji aorty u dorosłych i nastolatków: wczesne i średnioterminowe wyniki leczenia prowadzonego przez zespół interwencyjnego leczenia kardiologicznego dorosłych

Background: Stent implantation has evolved as an important therapeutic strategy for aortic coarctation. Aim: This study aimed to present the experience of aortic coarctation stenting using the Cheatham-Platinum stent by an Adult Interventional Cardiology Team. Material and methods: The data of 11 patients (ages were between 15 to 58 years) who underwent aortic coarctation stent implantation between 2008 and 2011 for moderate to severe native aortic coarctation were retrospectively collected. Results: Average systolic blood pressure was 175 ±35 mm Hg, and mean diastolic blood pressure was 115 ±15 mm Hg. Pressure gradient proximal and distal to aortic coarctation was 55.5 ±17.7 before the stenting. The invasive gradient decreased below 10 mm Hg in all patients. There were no complications except in one patient whose subclavian artery was occluded without any clinical finding. One patient had a totally occluded lesion, needing perforation for acquired interruption using a 0.35 inch hydrophilic wire under the supporting balloon. There was no aneurysm or restenosis at follow-up. Left ventricular functions completely recovered within 1 month in all patients. Conclusions: Stenting using the Cheatham-Platinum stent, either covered or bare, is safe in moderate to severe native aortic coarctation and provides an excellent transcoarctation gradient and clinical hypertension and left ventricular functional relief in adult patients.

Coarctation of Aorta-Management Options and Decision Making

Coarctation of the Aorta (CoA) is a congenital cardiac anomaly consisting of a constricted aortic segment with a prevalence of 5 to 8% of all Congenital Heart Defects (CHD). The classic CoA is located in the thoracic aorta distal to the origin of the left subclavian artery, at about the level of the ductal structure. Significant hypertension and/or congestive heart failure are indications of intervention. If hypertension (rather that heart failure) is the clinical problem, it is better to relieve the aortic obstruction promptly rather that attempting to “treat” hypertension with antihypertensive medications. Surgical relief of the aortic obstruction and catheter interventional techniques (balloon angioplasty and stents) are available alternatives. Since the introduction of surgical correction by Crafoord and Nylin and Gross and Hufnagel in early 1940s, surgical therapy has been the treatment of choice for aortic coarctation. Gruntzig’s technique of balloon angioplasty was adopted by Singer and Sperling and their associates to enlarge coarcted aortic segments in post-surgical recoarctation and native coarctation, respectively in early 1980s. This is followed by the application of the technique by other cardiologists to treat native CoA. The procedure consists of inserting a balloon angioplasty catheter across the site of coarctation and inflating the balloon with diluted contrast material. Both immediate and followup results are reasonably good. Residual and recurrent obstructions following surgery and prior balloon angioplasty are also amenable for balloon angioplasty. Despite reasonably good short-term and long-term results of balloon angioplasty, some problems remain and include restenosis, probability of aortic rupture, formation of aneurysms and inability to effectively treat long-segment tubular narrowing. Because of these and other reasons, endovascular stenting of aortic coarctation has gained acceptance over the last decade. The balloon catheter, with the stent mounted on it, is advanced over a stiff guide wire and positioned across the coarctation segment and the balloon inflated, thus implanting the stent. Most cardiologists use stents in adolescents and adults and restrict their use in younger children because of issues related to growth. Stent therapy appears to be an attractive method for treatment of native or recurrent coarctation, aneurysm formation following prior surgical or balloon intervention and for long segment hypoplasia. Role of covered stents to manage aortic coarctation is limited and are used when the assessed risk for development of aneurysm or dissection is high. A comparison of all available treatment modalities was made and while it is difficult to make a definitive statement, the overall data seem to indicate that transcatheter methods may be better than surgery. Selection of the method of therapy is largely based on the age at presentation and anatomy of the coarcted segment and surrounding structures; surgery for infants and long segment coarctations, balloon angioplasty for discrete native and post-surgical coarctations in children and stents for long segment coarctations as well as any type of coarctations in adolescents and adults seem to be the current trend.

Emergency surgical intervention after unsuccessful percutaneous transluminal angioplasty and stenting of aortic coarctation

Coarctation of thoracic aorta is an uncommon diagnosis in adults. Catheter-based intervention consisting of primary ballooning and stenting is becoming one of the methods of choice for the treatment of native coarctation. We describe the case of a young adult with coarctation of the aorta treated unsuccessfully with percutaneous transluminal angioplasty and stent implantation that resulted in stent migration into the aortic arch and led to an urgent operative intervention. In one step, we performed the evacuation of the foreign body from the aortic arch as well as the treatment of the aortic coarctation through an extra-anatomical vascular graft interposition between the ascending and descending thoracic aorta. In this article, we discuss the need for emergency surgical intervention in this case.

Dual wire technique for aortic coarctation stent placement

A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16-mm balloon and a 4-Fr catheter was advanced over the two wires within a 14-Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches.

288 Residual hypertension and aortic wall abnormalities at mid-term follow-up after native aortic coarctation stenting

The feasibility of transcatheter primary stenting (TPS) to treat native aortic coarctation (Coa) is well-demonstrated as an alternative of surgical repair. However, information on mid-term follow-up remains scarce, especially regarding the frequency of systemic hypertension and the integrity of the aortic arch. We retrospectively studied the patient's outcome after TPS for Coa, paying particular attention to residual hypertension and aortic wall abnormalities, including arch obstruction, aneurysm and dissection. Since 2002, 20 patients (8 female) with Coa were treated by TPS at a median age and weight of 21 (7 to 52) years and 60 (27 to 94) kg, respectively. They were symptomatic in all cases with upper limb hypertension in 16. Twenty stents were successfully implanted and the mean peak systolic pressure gradient dropped from 31 (10 to 60) mmHg to 1,6 (0 to 15) mmHg. One major complication occurred in a patient who experienced bilateral groin hematomas, with hypotension and anemia necessitating transfusion. After a median follow-up of 2,9 (0,12 to 7,8) years, the 20 patients are asymptomatic. Residual upper limb hypertension is present in 7 cases (35%), including 3 (15%) with mild residual upper-to-lower limbs gradient (20 mmHg). One patient was successfully redilated for in-stent restenosis. By transthoracic echocardiography (n = 20), spiral computed tomography (n = 4), and magnetic resonance imaging (n = 13), there is no aortic aneurysm or dissection. TPS for Coa is successful with minimal morbidity. After mid-term follow-up, residual hypertension is similar to that observed after surgical repair, whereas aortic wall abnormalities are not encountered. Longer term follow-up is mandatory to confirm this favorable outcome.

Multiple transcatheter interventions in the same session in congenital cardiopathies

Background:To investigate the methods of percutaneous transcatheter interventions for combined congenital heart disease and to evaluate its efficacy in children.Materials and Methods:Thirty cases (ages 3 days-13.5 years, body weight 3-35 kg) that underwent two multiple transcatheter interventions for combined or solitary congenital heart disease were retrospectively analyzed and presented.Results:A total of 61 transcatheter interventions were performed in 30 patients as combined procedures. In 29 patients, two different procedures were combined in the same session, in remaining one patient, combination of three interventions were performed in the same catheter session. Interventions performed in combined procedures were as follows: Coarctation balloon angioplasty in 12 cases, pulmonary balloon valvuloplasty in 10, PDA coil embolization in 10, aortic balloon valvuloplasty in 8, VSD closure in 5, ASD closure in 4, ductal stent implantation in 4, palliative pulmonary balloon valvuloplasty in 3, recanalization and angioplasty of the systemic-pulmonary shunt in 2, balloon atrial septostomy in one, aortic coarctation stent implantation in one, coil embolization of a pulmonary lobar sequestration in one and pulmonary valve perforation plus pulmonary balloon valvuloplasty in one were performed as first or second procedure. There was no mortality or major morbidity in relation to combined procedures.Conclusion:Multiple transcatheter interventions in the same session are feasible, safe and effective with satisfactory good results. Second intervention may be performed as complementary procedure or independently to the first intervention.

096 Endovascular stenting for native coarctation of the aorta using the CP Numed covered stent: Abstract 096 Table 1

Introduction Primary endovascular stenting is now a recognised alternative treatment strategy to surgical treatment for native coarctation in adults. The availability of covered stents has made coarctation stenting more attractive, with less periprocedural complications and long-term follow-up. Objective To assess early outcomes and blood pressure control in adults with a native aortic coarctation of the aorta undergoing primary endovascular stenting. DESIGN: - Primary data were collected prospectively from patients with native coarctation and systemic hypertension that underwent stenting of aortic coarctation using the CP Numed covered stent over 3 years period. Patients were assessed with 24 h ambulatory blood pressure monitoring (ABP) prior to the procedure (pre-stenting), at 6 weeks and 1 year following endovascular stenting. Results There were 23 patients (14 male). Twenty-one patients had procedure under general anaesthesia. The procedure was technically successful in all patients. Mean age was 34±14 years. Peak aortic gradient across the coarctation fell from 26±12 mmHg to 7±5 mmHg (p Conclusion Significant improvements in the clinical and ABP blood pressure following stenting with the CP Numed covered stent are seen at 6 weeks sustained at 1 year. However there is a continued need for anti-hypertensive therapy and long term follow-up is required. (*As compared to the pre-stenting).

Stenting of aortic coarctation: Acute, intermediate, and long‐term results of a prospective multi‐institutional registry—Congenital cardiovascular interventional study consortium (CCISC)

Since the 1980s, stent implantation has evolved as an important therapeutic strategy for coarctation of the aorta. However, available data is frequently flawed by short follow-up, lack of adequate follow-up imaging, and retrospective nature of data collection. Data was prospectively collected using a multicenter registry congenital cardiovascular interventional study consortium (CCISC). Between 2000 and 2009, 302 patients from 34 centers with a median weight of 58 kg underwent stent implantation for coarctation. Eligible patients (44%) completed intermediate follow-up (3-18 months) with integrated imaging (cath, CT, MRI), whereas 21% completed long-term follow-up (>18-60 months). Procedural success was defined as UL/LL systolic gradient of less than 20 mm Hg, lack of significant recurrent obstruction, and freedom from unplanned repeat intervention. Acute procedural success was 96%. Cumulative intermediate success was 86%, and cumulative long-term success was 77%. Unplanned repeat interventions were required in 4%, and aortic wall complications were seen in 1% of patients (dissection n = 1 and aneurysm n = 3). Other adverse events (n = 15) occurred mainly acutely and included technical complications such as stent malposition (n = 9). At long-term follow-up, 23% of patients continued to have systolic blood pressure above the 95th centile, 9% had an upper-to-lower limb blood pressure gradient in excess of 20 mm Hg, and 32% were taking antihypertensive medication. This study documented acute, intermediate, and long-term outcome data comparable or superior with other surgical or interventional series. However, even with successful initial stent therapy, patients continue to require long-term follow-up and have associated long-term morbidity, relating to aortic wall complications, systemic hypertension, recurrent obstruction as well as need for repeat intervention.

Stenting of aortic coarctation and exercise‐induced hypertension in the young

To evaluate whether the stenting of aortic coarctation enhance the risk of exercise-induced hypertension (EIH). There is the theoretical concern that aortic stents may cause increased aortic wall impedance and therefore systolic hypertension during exercise. Blood pressure and the Doppler derived peak and mean systolic pressure gradient (PSG and MSG) across the distal aorta at the peak of exercise were evaluated in young patients (mean age 14 +/- 3 years) with aortic coarctation successfully treated with surgery or with stent implantation at least 1 year before the test. Only patients who reached the 85% maximal predicted heart rate or whose exercise test was interrupted because of severe hypertension, and in whom significant aortic narrowings were excluded by a MRI or a CT scan performed in the six months preceding the exercise test were included in the study. Seventeen patients formed the surgery-group, while 15 patients the stent-group. Patients in surgery-group were younger at coarctation repair and with a longer follow-up than those in stent-group. No difference was present regarding age, body surface area, gender, and presence, and degree of mildly hypoplastic aortic segments between the two groups as well as between patients with or without EIH. EIH was found in 35% of surgery-group patients and in 33% of stent-group patients. PSG and MSG were similar in the patients with or without EIH. EIH can be found in a high number of young patients successfully treated for aortic coarctation but at intermediate follow-up stent implantation does not seem to enhance the risk of EIH.

Balloon expandable stent implantation for native and recurrent coarctation of the aorta—prospective computed tomography assessment of stent integrity, aneurysm formation and stenosis relief

BackgroundStenting for aortic coarctation is known to be effective in the medium term. Aneurysm formation following stent implantation is a recognised complication. However, data regarding aortic wall injury and stent...

Effect of endovascular stenting of aortic coarctation on biventricular function in adults

Objective:To investigate the effect of endovascular stenting of aortic coarctation on biventricular function in adults during intermediate-term follow-up.Methods:21 patients (age 34 (10) years) were studied prospectively before and 14 (2)...

Acute and intermediate outcomes, and evaluation of injury to the aortic wall, as based on 15 years experience of implanting stents to treat aortic coarctation

Stenting for aortic coarctation has been shown to be effective in the short term. The safety and longer term efficacy of transcatheter therapy, however, must be well established if the technique is to be widely accepted as an alternative to surgery. In order to determine the frequency, spectrum, and outcome of injury to the aortic wall caused by angioplasty or stenting of aortic coarctation, the nomenclature of mural injury in these patients must be adapted to the conditions of transcatheter therapy. Between 1989 and July 2005, we inserted stents in 153 patients with aortic coarctation, their median age being 15.8 years. Prior aortic interventions had been performed in 98 patients, and preexisting aneurysms were observed in 19. Stenting resulted in a significant reduction of the gradient across the site of coarctation, from a median of 30 millimetres of mercury to zero (p less than 0.001), with a residual gradient within the aortic arch of 20 millimetres of mercury or more in 5% of patients. Acute injuries to the aortic wall, other than therapeutic tears, were observed in 3 patients (2%), none of whom required surgery. At median follow-up of 2.5 years, this being more than 5 years in 30 patients, 4 patients had died, albeit none from complications relating to stenting or catheterization. Acute injuries to the aortic wall did not progress, and new aneurysms were observed in 6% of patients subsequent to follow-up imaging. Stent fractures, and jailed or partially covered brachiocephalic vessels, were observed in 12, and 49, patients, respectively, but did not result in haemodynamic or embolic complications. Stenting for aortic coarctation results in consistent relief of the gradient, and few serious complications in the short and intermediate term. Serious injuries to the aortic wall are uncommon in our experience, and can be minimized with a focus on technical measures, such as pre-dilation before stenting.