Adult Coarctation Research Articles

Cardiovascular changes after transcatheter endovascular stenting of adult aortic coarctation

Cardiovascular changes after transcatheter endovascular stenting of adult aortic coarctation

The Mid-term Result of Patch Aortoplasty for Adult Coarctation of the Aorta: The Report of Three Cases

要 旨：近年，成人大動脈縮窄症の治療に対しステントを用いたカテーテル治療が行われるようになり，手術との優劣が論じられるようになってきている。手術方法には以前より種々の方法が採用されており，いまだに議論のあるところである。今回，われわれは再手術の2症例を含む3症例に対して，血管アクセスの観点などからステントなどカテーテル治療は適当でないと判断し，手術侵襲，血管の性状からパッチ拡大術を施行した。術後遠隔期において重篤な合併症もなく良好な結果が得られたので，文献的考察を交えて報告する。

Surgical Repair of Adult Coarctation in Auckland

Surgical Repair of Adult Coarctation in Auckland

Percutaneous treatment of native aortic coarctation in adults

Aortic coarctation is a common congenital cardiac defect, which can be diagnosed over a wide range of ages and with varying degrees of severity. We present two cases of patients diagnosed with aortic coarctation in adulthood. Both patients were treated by an endovascular approach. These cases demonstrate the variety of indications in which percutaneous treatment is an excellent alternative for surgical treatment in adult native coarctation patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s12471-011-0198-x) contains supplementary material, which is available to authorized users.

Redo sternotomy for extra-anatomical correction of aortic coarctation and mitral repair in an adult after failed endovascular treatment

Recently, extra-anatomical bypass surgery has been widely used in complicated adult aortic coarctation cases with concomitant intracardiac repair. Stent implantation has been widely used for primary aortic coarctation as well. The procedure has been shown to be effective with long term follow ups. However, failed stent implantations like stent fracture and dislodgement may complicate the clinical status and subsequent surgical procedure. Extra-anatomic bypass can provide effective results and lower morbidity in cases with concomitant intracardiac problems and stent failure. Here we present an adult aortic coarctation patient who had undergone a Bentall operation and two unsuccessful stent implantations for recurrent aortic coarctation. The patient then got an extra-anatomic bypass for aortic coarctation and concomitant mitral valve commissurotomy through median sternotomy.

Cheatham-Platinum stent for native and recurrent aortic coarctation in children and adults: immediate and early follow-up results

To present our institutional experience of endovascular Cheatham-Platinum stent implantation in children and adults with native and recurrent aortic coarctation. Between August 2007 and November 2009, 45 patients had aortic coarctation treated with 47 stents implantation. We preferred primarily stent implantation in adult patient with coarctation, in children more than five years-old it is preferred in cases of aneurysm, subatretic or blind coarctation and coarctation with patent ductus arteriosus or in restenosis. Files of stent-implanted patients were retrospectively analyzed in terms of patients' demographic features, echocardiographic and angiographic findings both before and after procedure. Patients were grouped as Group 1: native coarctation and Group 2: recoarctation developed after either surgery or balloon angioplasty. Findings of the cases' were compared using paired and unpaired Student's t, Mann-Whitney U and Chi-square tests. Sixteen covered and 31 bare totally 47 balloon expandable stents were implanted in 45 patients. The mean follow up duration was 12.1 ± 7.1, median 11 months (2-29 months). There was no procedure related death. In two patients two stents were implanted in tandem. While the coarctation of the aorta was native in 26 patients (functionally interrupted aortic arch in one), recoarctation was detected in 7 patients after surgery, in 8 patients after balloon angioplasty, in 4 patients both after surgery and balloon angioplasty. One patient had functionally interrupted aortic arch perforated with guide wire and then covered stent implanted. The mean age 12.2 ± 5.9 years (5-33 years) and mean body mass index was 21 ± 3.7 kg/m2 (14.8-31 kg/m2). Considering all cases, a statistically significant decrease in both the invasive and echocardiographic gradients (p<0.001 for both) and statistically significant increase in lesion diameter (p<0.001) were detected. The decrease in invasive and echocardiographic gradients and increase in lesion diameter is statistically significant in each group also (p<0.001, <0.001 and <0.001 for both groups, respectively). Before the procedure, the invasive gradient was significantly higher and the lesion diameter was significantly lower in group I than in group II (p=0.002 and p=0.005, respectively). Also the percentage of decrease in gradient and increase in diameter was statistically higher in group 1 than in group 2 (p=0.04 and p=0.04). Our early and short- term follow-up results indicate that stent implantation is safe and very effective in reducing coarctation gradient and increasing lesion diameter both in native coarctation and recoarctation.

Our initial experience with stent implantation for aortic coarctation in adults

We evaluated the procedural success and short-mid term results of stent implantation for aortic coarctation in adults. The study included 15 consecutive patients (9 women, 6 men; mean age 27±7 years; range 17 to 45 years) treated with stent implantation for aortic coarctation. Fourteen patients had native, one patient had recurrent coarctation. Nine patients received bare metal and six patients received covered Cheatham-Platinum stents. Covered stents were used in patients with accompanying patent ductus arteriosus (n=2), severe coarctation (n=3), and recurrent coarctation (n=1). Procedural success was defined as the reduction in the pressure gradient across the coarctation site to less than 20 mmHg. The mean follow-up period was 10.4±4.6 months (range 3 to 18 months). Stent implantation was successful in all the patients. Compared to the preprocedure figures, systolic gradient across the aortic coarctation decreased from 37.2±11.3 mmHg to 3.5±2.9 mmHg, the diameter of the coarcted aortic segment increased from 5.4±1.5 mm to 17.2±1.4 mm, and systolic blood pressure declined from 154±9.7 mmHg to 130±7.3 mmHg following stenting (for all, p<0.001). There were no procedure-related major complications. Stent implantation for aortic coarctation in adults is a safe and effective alternative to surgical correction.

Is endovascular repair for patients with primary adult coarctation, bicuspid aortic valve, dilated ascending aorta and hypertension the new gold standard?

Is endovascular repair for patients with primary adult coarctation, bicuspid aortic valve, dilated ascending aorta and hypertension the new gold standard?

Adult Coarctation of Aorta With Post-Stenotic Calcified Aortic Aneurysms

Adult Coarctation of Aorta With Post-Stenotic Calcified Aortic Aneurysms

Open Surgical Repair and Endovascular Treatment in Adult Coarctation of the Aorta

The aim of this study was to compare the results of endovascular therapy (covered stenting) with surgical technique to repair aortic coarctation in adults. A prospective study of 11 patients who were treated during the past 10 years was carried out. Of these, five patients underwent endoprosthesis (group A) and six an open surgical repair (group B). Follow-up comprised monitoring of the blood pressure, echocardiography, and computed tomography and magnetic resonance angiographic studies. The mean age of the patients was 46 years (range: 17-67 years) and the mean follow-up was 52.6 months (range: 1-117 months; 32.3 for group A vs. 69.7 for group B; p = 0.01). Two cases in group A were recoarctations after child angioplasty. The rate of postoperative complications was 27.7% (one hemothorax for group A vs. one pneumothorax and one hemothorax for group B); however, mortality did not occur. The success rate of the endovascular technique was 80%. The stay in the intensive care unit was 2.3 days with significant differences (one group A vs. three group B; p = 0.01), whereas length of hospital stay was 11 days (7.8 group A vs. 11.83 group B; p = 0.17). The pressure gradient across the stenosis decreased by 21.9 ± 3.7 mm Hg (24.5 ± 4.3 group A vs. 33 ± 3.2 group B). Six patients (54.5%) showed persistent hypertension (80% group A vs. 33% group B), with a mean residual pressure gradient of 23.4 ± 4.3 mm Hg (22.5 ± 5.4 group A vs. 22 ± 2.1 group B; p = 0.58). Short- and medium-term results of the endovascular therapy are similar, with shorter stay in the intensive care unit and higher necessity of antihypertensive treatment. Echocardiography and Doppler aortic coarctation gradients slightly higher than 20 mm Hg are usual during follow-up.

Balloon angioplasty for adult coarctation of aorta: a 6-month follow-up study

La radiothérapie apparaît relativement efficace dans le traitement des gliomes malins de l'adulte. De ce fait, la potentialisation de l'effet de cette dernière apparaît logique. De plus, l'utilisation d'une chimiothérapie précoce avant, ou au cours de la radiothérapie, est séduisante car à ce moment-là, la barrière hématoencéphalique semble plus largement perméable, permettant une pénétration et une diffusion des produits cytotoxiques hydrosolubles plus aisée. Sur ces bases théoriques, plusieurs équipes ont testé l'efficacité d'une chimioradiothérapie concomitante dans le traitement des gliomes malins. Malheureusement, l'analyse de ces études est difficile, car, la plupart portent sur un petit nombre de patients souvent disparates en termes d'âge, de diagnostic histologique et de gravité de l'atteinte neurologique. De plus, les protocoles et les produits utilisés sont différents d'une étude à l'autre, ce qui rend toute comparaison impossible. Les données de la littérature sont donc pour l'instant insuffisantes pour que l'on se fasse une idée claire de l'intér^et de l'association d'une chimioradiothérapie concomitante dans le traitement des gliomes malins, mais les premiers travaux ne sont guère encourageants et ne semblent pas montrer une efficacité supérieure à la radiothérapie seule.The prognosis of adult patients with malignant gliomas remains poor despite advances in neurosurgery and radiotherapy. Even if chemotherapy has done little to improve on these results, except in the treatment of oligodendrogliornas, many authors have proposed to test the effect of radiotherapy by adding concomitent chemotherapy. Unfortunatly, the analysis of these studies is difficult because all these protocols are different with a small number of patients. Furthermore, there are only a few studies evaluated in well controlled clinical trials with homogeneous patient population. Important factors such as tumor grade, patient age, and Karnofsky score, which have a strong influence on survival in malignant gliomas, are not clearly evaluated. Whatever, all these studies suggest that concomitent radio-chemotherapy seems not be promising in the treatment of malignant gliomas.

Endovascular stenting for aortic (re)coarctation in adults.

Objectives. Stenting for native and recurrent coarctation (COA) in adults has become an important therapeutic strategy. In this prospective observational study we evaluated the intermediate-term outcome of stent implantation for either native or recurrent (re)COA in adults.Methods. All adults who underwent stent implantation in our institution between January 2003 and December 2008 were included. Diagnosis of (re)COA was based upon a combination of clinical signs, noninvasive imaging or invasive gradient measurements. NuMED stents were implanted under general anaesthesia.Results. Twenty-four patients (50% male) underwent stent implantation for native (n=6) or reCOA (n=18) at a median age of 36 (18 to 60) years. There was significant improvement in pre- versus post-stent invasive systolic gradient (19 vs. 0 mmHg, p<0.001) and COA diameter (10 vs. 16 mm, p<0.001). Acute complications (12.5%) included death due to aortic rupture despite immediate successful coverage with a covered stent (n=1) and groin haematoma (n=2). During a median follow-up period of 33 (8 to 77) months (n=22), late complications occurred in three patients (13.6%): stent migration to the ascending aorta (n=1), pseudoaneurysm at the site of the initial stent (n=1), and occluded external iliac artery (n=1). Stent implantation did not reduce the need for antihypertensive medication or blood pressure at last follow-up. Conclusion. COA stenting results in a significant gradient decrease and increase in vessel diameter. However, serious complications do occur and hypertension remains in the majority of patients. (Neth Heart J 2010;18:430-6.).

Editorial commentEndovascular repair for adult coarctation: stating the obvious!

Editorial commentEndovascular repair for adult coarctation: stating the obvious!

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).

Adult Coarctation of Aorta Presenting as Aortic Dissection

Adult Coarctation of Aorta Presenting as Aortic Dissection

Physiologic Tailoring of Treatment in Resistant Hypertension

Resistant hypertension is a major opportunity for prevention of cardiovascular disease. Despite widespread dissemination of consensus guidelines, most patients are uncontrolled with approaches that assume that all patients are the same. Causes of resistant hypertension include 1) non-compliance 2) consumption of substances that aggravate hypertension (such as salt, alcohol, nonsteroidal anti-inflammatory drugs, licorice, decongestants) and 3) secondary hypertension. Selecting the appropriate therapy for a patient depends on finding the cause of the hypertension. Once rare causes have been eliminated (such as pheochromocytoma, licorice, adult coarctation of the aorta), the cause will usually be found by intelligent interpretation (in the light of medications then being taken) of plasma renin and aldosterone.If stimulated renin is low and the aldosterone is high, the problem is primary aldosteronism, and the best treatment is usually aldosterone antagonists (spironolactone or eplerenone; high-dose amiloride for men where eplerenone is not available). If the renin is high, with secondary hyperaldosteronism, the best treatment is angiotensin receptor blockers or aliskiren. If the renin and aldosterone are both low the problem is over-activity of renal sodium channels and the treatment is amiloride. This approach is particularly important in patients of African origin, who are more likely to have low-renin hypertension.

Is endovascular repair the new gold standard for primary adult coarctation?☆

Primary adult aortic coarctation (PAAC) is an unusual cause of hypertension. The standard of care includes surgical repair, which can be associated with considerable morbidity and operative risk. Although balloon angioplasty has been successfully used in paediatric and adolescent patients with coarctation, little information exists regarding the endovascular repair of PAAC. This study examines the procedural safety and efficacy of endovascular repair of PAAC along with midterm outcomes. Between January 2000 and July 2008, 16 patients underwent endovascular repair of PAAC. All patients were hypertensive with 13 patients (81.3%) receiving medical therapy. Symptoms included chest pain (n=11, 69%), progressive fatigue (n=5, 31%), exercise intolerance (n=4, 25%) and shortness of breath (n=3, 19%). Associated cardiac concerns included depressed ejection fraction (n=6, 38%), pulmonary hypertension (n=5, 31%), ascending aortic dilatation (n=5, 31%) and bicuspid aortic valve (n=4, 25%). Endovascular repair was achieved using a percutaneous femoral approach. Balloon angioplasty of the coarctation was performed prior to treatment using a balloon-expandable uncovered stent. Aortic diameters were assessed using intravascular ultrasound. Pre- and post-procedure pressure gradients were measured and success was determined as a residual pressure gradient across the treated aorta of less than 20 mmHg. The male:female (M:F) ratio was 9:7 with a mean age of 39.7 years. Procedural success was 100%. Mean pre-procedural aortic diameter was 8.4mm (3-14 mm) and mean post-procedural aortic diameter was 16.3mm (10-20mm) (p=0.04). The mean pre-procedural pressure gradient was 48.3 mmHg (25-100 mmHg) and the mean post-procedural pressure gradient was 0.5 mmHg (0-15 mmHg) (p=0.05). Twelve patients received one stent, two patients received two stents, one patient received three stents and one other patient received a thoracic stent graft. The rate of paraplegia was 0% with no blood transfusions, strokes or deaths. Follow-up ranged from 12 to 72 months (mean=22.8 months). One patient required re-intervention with an additional stent 14 months following the initial procedure and all the patients remain symptom-free. Endovascular repair of PAAC is safe and effective and compares favourably with open surgical repair. Midterm follow-up suggests that the treatment is durable and may be an alternative to surgical repair. Although this is the largest endovascular treatment series for PAAC reported to date, additional study and follow-up are needed.

Extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation

To review the experience of extraanatomic aortic bypass grafting for the treatment of complex aortic coarctation. From July 1997 to July 2008, 48 consecutive patients (median age 30 years; range 10 to 58 years) with complex aortic coarctation underwent extraanatomic aortic bypass grafting. Indications include: (1) coarctation with intracardiac anomaly (n = 28); (2) coarctation with ascending aortic aneurysm (n = 1); (3) adult coarctation with calcification of local aortic wall (n = 7); (4) coarctation with hypoplasia aortic arch (n = 4); (5) long or multiple coarctation segment (n = 4); (6) coarctation with poststenotic aneurysm (n = 1); and (7) recurrent coarctation (n = 3). Routing of the grafts was:ascending-to-posterior pericardial descending aorta (n = 37); ascending-to-infrarenal abdominal aorta (n = 9); left subclavian artery-to-descending aorta(n = 2). Concomitant cardiac operations were performed in 31 patients (65%) using cardiopulmonary bypass; procedures included: aortic valve replacement in 16; mitral valve repair or replacement in 9; Bentall procedures in 6; patent ductus arteriosus closure in 5; ascending aortic replacement or plasty in 4; ventricular septal defect closure in 3 and coronary artery bypass surgery in 2. There was no operative death. One patient died of septic shock 39 days postoperatively. Two patients received laparotomy because of mechanical ileus shortly after the ascending-to-subrenal abdominal aortic bypass. Mean systolic blood pressure gradient between upper and lower extremities decreased from (65 +/- 27) mm Hg preoperatively to (14 +/- 11) mm Hg postoperatively (P < 0.05). During a mean follow-up of 28.9 months, there were no late deaths or graft-related complications. Residual mild hypertension were observed in five patients. Extraanatomic aortic bypass is an attractive treatment option for complex aortic coarctation in adults and adolescents. It can be performed with low morbidity and mortality. The midterm results is favorable.

Repair of Aortic Coarctation in an Adult by Direct Aortoplasty

Various techniques have been proposed for surgical correction of aortic coarctation in adults. We describe direct aortoplasty repair in a 28-year-old woman with native coarctation. Four-year follow-up with magnetic resonance angiography confirmed a good result. This is a safe and effective technique that provides enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.

Endovascular management of adult coarctation and its complications: intermediate results in a cohort of 22 patients☆

To determine the safety and effectiveness of current endovascular treatment in adult patients with thoracic aortic coarctation and its complications. A cohort of 22 patients was treated for late presenting primary or recurrent coarctation or aneurysmal formation at varying intervals following childhood intervention. Ten patients with recently discovered de novo coarctations were treated with balloon-expandable stents, and an endoluminal graft (ELG) was used in one additional patient. In the other 11 patients with recurrent lesions, three underwent repeat balloon dilation and stenting; eight patients with recurrence with aneurysms received ELGs. The gradients across the coarctation decreased from 49 + 16 to 4 + 7 mmHg (p = 0.001), and the diameters increased from 10 + 4 to 19 + 4mm (p = 0.001). In five of the eight patients (63%) with aneurysms, the ELG covered the subclavian artery, and a carotid subclavian bypass was necessary. Two patients required iliac artery access. No early major complications occurred. At mean follow-up of 31 + 15.6 months, one patient with type II leak resolved spontaneously and another developed neck dilation and type I leak, requiring a second ELG placement. All patients except one had improvements in symptoms and better hypertension control. We conclude that primary or secondary endovascular intervention in adults with de novo or recurrent coarctation and aneurysms is feasible with good intermediate results.