Coarctation Of The Aorta Diameter Research Articles

Evolving Utilization of Covered Stents for Treatment of Aortic Coarctation: Report From the IMPACT Registry.

Covered stent (CS) use for the transcatheter treatment of coarctation of the aorta (COA) was first described over 20 years ago. The covered Cheatham-platinum stent received Food and Drug Administration approval for COA treatment in 2016. Data collected as part of the National Cardiovascular Data Registry IMPACT registry were evaluated for contemporary usage patterns of CS for the treatment of COA from 2016 to 2021. Version 2 of the IMPACT registry was queried for all patients who underwent stent placement for treatment of COA from 2016 to 2021. Trends in CS use were evaluated by year and age of patient at the time of implant. Analysis was limited to clinical factors collected as part of the registry and was performed to identify factors associated with CS use. Data were available for 1989 case entries. Most patients (92%) received a single stent. The overall percentage of CS use in the cohort was 23% and remained consistent throughout the study period. The probability of CS use was significantly associated with increasing patient age at implant. Additional factors associated with CS use included smaller initial COA diameter, native COA, and the presence of a pseudoaneurysm. Procedural adverse event rates were low. CS use to treat COA was more common in adult patients and remained stable over the study period. Factors associated with CS use, including smaller COA diameter and aortic pseudoaneurysm, demonstrate the perceived value of CS as a tool to reduce the risk of aortic wall injury during treatment of COA.

Large Diameter Advanta V12 Covered Stent Trial for Coarctation of the Aorta: COARC Study.

Covered stent implantation for treatment of coarctation of the aorta (CoA) is effective and can prevent aortic wall injury. Prospective studies with long-term follow-up, including imaging, are lacking. We report the acute and long-term outcomes for use of the Large Diameter Advanta V12 covered stent for treatment of native and recurrent CoA. A prospective, multicenter, nonrandomized study was performed including 70 patients (43 male), median age 17 years, median weight 57.4 kg with CoA who underwent implantation of the Large Diameter Advanta V12 covered stent. Annual follow-up for 5 years included Doppler echocardiography to calculate diastolic velocity: systolic velocity ratio. CoA diameter increased from 5.6±3.6 to 14.9±3.9 mm (P<0.0001) and the pressure gradient decreased from 35.8±16.2 to 5.6±7.9 mm Hg (P<0.0001). Preimplantation diastolic velocity:systolic velocity of 0.6±0.16 dropped to 0.34±0.13 (P<0.0001) and was maintained at 5 years. Computed tomography angiograms at 12 months postimplantation demonstrated the stent:transverse arch diameter to be similar, 0.91±0.09 to postprocedure 0.86±0.14. Major adverse vascular events at 30 days and 12 months were 1.4% and 4.3%, respectively. Significant adverse events included three patients who required stent implantation to treat infolding. There were no mortalities. The Large Diameter Advanta V12 covered stent is safe and effective for the treatment of CoA with an immediate and sustained reduction of the pressure gradient over 12 months and 5 years as assessed by preimplantation and postimplantation Doppler echocardiography and 12-month computed tomography angiography. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00978952. URL: http://www.anzctr.org.au; Unique identifier: ACTRN12612000013864.

Balloon Angioplasty for Native Aortic Coarctation in 3- to 12-Month-Old Infants.

Balloon angioplasty for native coarctation of the aorta (CoA) is successful in children and adults but in neonates results in frequent restenosis. The efficacy of balloon angioplasty for native CoA during infancy beyond the neonatal period was examined in infants aged 3 to 12 months of age. A retrospective review of 68 infants who underwent balloon angioplasty for native CoA. 95% CI are in parentheses. Procedural age was (mean±SD) 6±3.4 months and weight was 7±1.8 kg. Balloon angioplasty produced a large decrease in both the noninvasive arm-to-leg blood pressure gradient (41.2±18.7 to 5.6±9.6 mm Hg) and the invasive peak systolic pressure gradient (34±12 to 11±9 mm Hg). Balloon angioplasty increased the CoA diameter from 2.7±1 mm to 4.6±1.2 mm. One patient was lost to follow-up. A catheter reintervention was required in 11.8% and surgery in 10.3%. The hazard of reintervention was highest early. Median freedom from reintervention was 89% (95% CI, 80%-96%) at 1 year, 83% (95% CI, 73%-92%) at 5 years, and 81% (95% CI, 69%-90%) at 10 years. Femoral artery thrombosis was documented in 6 (9%) infants without any long-term consequence. One patient developed a small aortic aneurysm late and has not required treatment. A robust estimate of the frequency of aortic aneurysms remains to be determined as the majority of subjects have not had cross-sectional imaging. Balloon angioplasty of native CoA is effective and safe in infants aged 3 to 12 months with outcomes comparable to those in older children and adults. Catheter reinterventions can avoid the need for surgery in most patients.

P588Flow profile for a better non-invasive pressure drop in CoA

Abstract Introduction In cardiovascular obstructions, as Coarctation of the Aorta (CoA), guidelines recommend treatment based on a relevant pressure drop (ΔP). Diagnostic ΔP is estimated by simplified Bernoulli (SB) and is measured as peak-to-peak (PtP) ΔP via catheterization. The divergences amid methods are understood, but it is common practice to widely and positively accept both as valid diagnostic. Recently, simplified advective work-energy relative pressure (SAW) to correct SB by considering the full velocity profile for the ΔP computation. Purpose To verify the correctness of peak flow derived pressure drop via maximal velocity (SB), and full flow profile (SAW) versus clinical gold-standard PtP ΔP in a CoA phantom. Methods An MRI-compatible and pulsatile CoA phantom was built and tested in eight configurations, with four levels of obstruction (9, 11 and 13 mm CoA diameter and no CoA) under two flow regimes (stress and normal). The ΔP was measured via catheterization between ascending and in descending aorta (DA) as instantaneous and as PtP. Also, MRI 4D-flow velocity vector fields were acquired, enabling the ΔP estimation by SB and SAW at effective orifice area (EOA) and DA catheterization locations. at the point of the effective orifice area (EOA) and at DA catheterization location. Results The disparity in ΔP illustrate the fundamental differences between methods (figure and table). Catheterised instant and PtP ΔPs are similar for the CoA phantom configurations, where SB and SAW are valid. The lesser the obstruction, the greater is the temporal acceleration contribution to the ΔP and discrepancies between methods arise. As recognised, SB is an overestimation of the catheterization measurements. The most equivalent ΔPs are the catheterization PtP and SAW. Velocity-based ΔPs (SB and SAW) show a drop in performance when the velocity is captured at the DA instead of the right EOA point, illustrating the sensitivity to the acquisition location. Peak ΔPs per method and per phantom 9mm CoA 11mm CoA 13mm CoA Normal R2 Linear eq. rest stress rest stress rest stress rest stress Instant ΔP 33.4 45.7 11.5 19.6 12.1 14.5 −2.7 −12.2 0.949 y=1.12x PtP ΔP 29.3 43.5 10.0 16.0 5.8 11.2 −1.8 -3.6 – – SB EOA 37.5 52.3 13.4 22.3 6.1 11.4 1.4 1.4 0.988 y=1.23x SB DA 22.6 59.8 10.7 18.6 5.2 8.5 0.9 1.2 0.893 y=1.15x SAW EOA 29.9 51.4 11.3 19.0 4.9 9.7 0.8 0.8 0.972 y=1.11x SAW DA 11.74 28.3 5.5 9.9 2.7 4.5 0.6 0.7 0.911 y=0.56x Linear comparisons were made against gold-standard catheterised PtP ΔP. Velocity meshes and ΔPs in cardiac cycle Conclusions Initial phantom evidence suggests that the non-invasive ΔP assessments based on flow should consider the full flow profile and be acquired at the point of EOA. Acknowledgement/Funding PIC project, European Union's Horizon 2020 Marie Skłodowska-Curie ITN Project under grant agreement No 764738

Self-Expanding Versus Balloon-Expandable Stents in Patients With Isthmic Coarctation of the Aorta

Endovascular stent implantation has become the treatment of choice for the management of patients with native coarctation of the aorta (CoA). The aim of this study was to compare the outcomes of self-expandable stenting (SES) with balloon-expandable stenting (BES) in the treatment of native CoA. In this single-center retrospective study, all patients who underwent SES or BES for the management of native CoA were enrolled. Patients were followed up for a median period of 35 (inter-quartile range 15 to 71) months. The primary outcome of interest was a composite end point consisted of death, surgical repair, re-stenting, re-ballooning, and hospital admission for hypertension crisis. The CoA diameter has changed from 3.2 ± 2.1 to 14.2 ± 4.0 mm in the BES group and from 4.6 ± 2.6 to 12.2 ± 3.7 mm in the SES group (both p <0.001). The procedure was successful with residual pressure gradient <20 mm Hg in 99.0% and 98.6% of patients in the BES and SES groups, respectively. Major adverse events occurred in 6 (8.7%) in the SES groups and 14 (20.3%) in the BES group (p = 0.053). Kaplan-Meier curve showed no difference between the 2 groups in terms of survival from major adverse events (p = 0.10), but when groups were matched for the propensity of stenting methods, SES was associated with lower major adverse events (p = 0.01). In conclusion, the SES and BES methods were safe and durable in our cohort with low rates of adverse events. After adjustment for the propensity of treatment with each stenting method, SES was associated with better outcomes. Regardless of the outcome of each method, it should be noted that the taken approach should be tailored to the patient's anatomy.

Experience With the Atrium Advanta Covered Stent for Aortic Obstruction

We sought to assess the efficacy, safety and clinical outcomes of the Advanta V12™ covered stent in management of coarctation of the aorta (CoA). Stent functionality was assessed by review of angiographic imaging, clinical data at admission, discharge and at the last clinic visit, stent configuration on chest roentgenogram, radiation exposure, and complications. Between October 2009 and February 2012, 17 patients underwent stent implantation. There were 9-12, 2-14, and 6-16 mm diameter stents deployed. Balloon angioplasty after implantation was required in 2 patients. Mean percent recoil in the middle of the stent for the 12, 14, and 16 mm implants was 14%, 24%, and 24%, respectively. There was improvement in CoA diameter from 6.6 ± 3.2 to 11.5 ± 1.7 mm (P<0.0001) and a reduction in the peak pressure gradient from 23.1 ± 10.1 to 0.8 ± 3.3 mmHg (P<0.0001). No patient had a symptomatic complication. Left arm cuff blood pressure fell 24 hours after implantation and left arm to leg blood pressure gradient fell to <20 mmHg in all (P<0.0001). Follow-up was a median 242 days and at the last clinic visit there were no statistically different findings from discharge. Five children (33%) required antihypertensive medications but 3 were off medication at latest follow-up. Three patients (18%) required reintervention. The implantation of the Advanta™ V12 stent for the treatment of CoA is safe and effective in the early term. However, further study is required to determine longer-term stent efficacy.

Acute outcome of stent therapy for coarctation of the aorta: Results of the coarctation of the aorta stent trial

The coarctation of the aorta stent trial (COAST) is a pivotal trial of the NuMED Cheatham Platinum Stent(®) for treatment of coarctation of the aorta (CoA). CoA is a congenital obstruction to flow through the aorta. Stents have been used since the 1990s to treat CoA; none have been approved by the Food and Drug Administration for this indication. In a prospective, multicenter study 105 patients received stents for treatment of CoA. Data was collected in the catheterization laboratory, on discharge and at 1-month postprocedure. Of 105 patients, 69% were male; 57% had native CoA. Noninvasive, baseline systolic blood pressure (SBP) showed upper extremity (UE) SBP to be 140 ± 16 mm Hg and UE to lower extremity (LE) SBP difference 29 ± 17 mm Hg. At catheterization, baseline ratio of minimum CoA diameter to diameter of descending aorta (CoA:DAo) was 0.46 ± 0.16. Implants (104/105) were successful with one stent migration. There were no deaths or serious complications. Paradoxical hypertension occurred in 6%. Four percent of patients experienced somewhat serious adverse events related to the procedure. All patients achieved relief of ascending aorta to Dao pressure gradient: mean = 2.0 ± 4.0 mm Hg (P < 0.001). The CoA:DAo increased to 0.84 ± 0.18. At 1-month, UE SBP was 120 ± 12 mm Hg, UE to LE SBP difference = -1 ± 12 mm Hg. Ninety-nine percent of patients had UE to LE SBP difference <20 mm Hg. Stenting of CoA, using the NuMED Cheatham Platinum Stent, is acutely safe and effective for treatment of CoA.

Balloon Angioplasty for Native Coarctation of the Aorta in Neonates and Infants With Congestive Heart Failure

Balloon angioplasty (BA) is an alternative to surgical repair for coarctation of the aorta (CoA) in children. However, its role in the treatment of native CoA in neonates and infants remains controversial. The purpose of this study was to report the midterm outcomes of BA for native CoA in neonates and infants with congestive heart failure (CHF). Between July 2000 and March 2007, 18 neonates and infants with native CoA and CHF who underwent BA were enrolled. Patients without recoarctation were designated as group A, while those with recoarctation or CHF were designated as group B. The clinical presentations, laboratory data, and outcomes were compared between groups. There were 10 patients in group A and eight in group B. The mean age was 2.8 +/- 3.1 months (range, 0.7-11 months). Mean body weight was 4.0 +/- 1.9 kg (range, 2.1-8.0kg). CHF improved markedly in all patients immediately after BA, with a reduction in systolic pressure gradient from 36.4 +/- 12.0 to 5.6 +/- 6.0 mmHg (p < 0.001). The recoarctation rate was 44% (8/18). The risk factors for restenosis were post-BA systolic pressure gradient >10 mmHg (p = 0.007) and CoA diameter <3 mm (p = 0.013). The outcomes of BA for native CoA in neonates and infants with CHF remain poor. The incidence of recoarctation is high in neonates and patients whose post-BA systolic pressure gradient is >10 mmHg or whose CoA diameter is <3 mm.

Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults

More information is needed to clarify whether stenting is superior to balloon angioplasty (BA) for unoperated coarctation of the aorta (CoA). From September 1997, 21 consecutive adolescents and adults (24 +/- 11 years) with discrete CoA underwent stenting (G1). The results were compared to those achieved by BA performed in historical group of 15 patients (18 +/- 10 years; P = 0.103; G2). After the procedure, systolic gradient reduction was higher (99% +/- 2% vs. 87% +/- 17%; P = 0.015), residual gradients lower (0.4 +/- 1.4 vs. 5.9 +/- 7.9 mm Hg; P = 0.019), gain at the CoA site higher (333% +/- 172% vs. 190% +/- 104%; P = 0.007), and CoA diameter larger (16.9 +/- 2.9 vs. 12.9 +/- 3.2 mm; P < 0.001) in G1. Aortic wall abnormalities were found in eight patients in G2 (53%) and in one in G1 (7%; P < 0.001). There was no major complication. Repeat catheterization (n = 33) and/or MRI (n = 2) was performed at a median follow-up of 1.0 year for G1 and 1.5 for G2 (P = 0.005). Gradient reduction persisted in both groups, although higher late gradients were seen in G2 (median of 0 mm Hg for G1 vs. 3 for G2; P = 0.014). CoA diameter showed no late loss in G1 and a late gain in G2 with a trend to being larger in G1 (16.7 +/- 2.9 vs. 14.6 +/- 3.9 mm; P = 0.075). Two patients required late stenting due to aneurysm formation or stent fracture in G1. Aortic wall abnormalities did not progress and one patient required redilation in G2. Blood pressure was similar in both groups at follow-up (126 +/- 12/81 +/- 11 for G1 vs. 120 +/- 15/80 +/- 10 mm Hg for G2; P = 0.149 and 0.975, respectively). Although satisfactory and similar clinical outcomes were observed with both techniques, stenting was a better means to relieve the stenosis and minimize the risk of developing immediate aortic wall abnormalities.

Echocardiographic Indices of Doppler Flow Patterns Compared with MRI or Angiographic Measurements to Detect Significant Coarctation of the Aorta

Evaluation for the presence and severity of coarctation of the aorta (CoA) by two-dimensional echocardiography alone can be difficult. The purpose of this study was to use Doppler velocity and pressure gradient half-time in systole and diastole to estimate CoA severity. Doppler echocardiograms of children with suspected CoA and either an aortic angiogram or thoracic magnetic resonance imaging (MRI) performed within 1 month of the echocardiogram were evaluated. Patients with patent ductus arteriosus, significant aortic insufficiency, long tubular CoA, or CoA outside the thorax were excluded. Measured Doppler variables, indexed for heart rate, included systolic velocity half-time (sVHTi), diastolic velocity half-time (dVHTi), systolic pressure half-time (sPHTi), and diastolic pressure half-time (dPHTi). For each of these variables, sensitivity and specificity to detect a significant CoA were determined. A significant CoA was defined as a ratio of the CoA diameter to the diaphragmatic aortic diameter of < 0.5 as imaged by MRI or angiography. Indexed systolic velocity and pressure half-times were found not to be significant predictors for CoA. For the Doppler parameter dVHTi, using a critical value of > 200 msec indexed, we found a positive predictive value of 87% and a negative predictive value of 80%. The parameter dPHTi, using a critical value of > 75 msec indexed, demonstrated positive and negative predictive values of 92% and 79%, respectively. Measurement of dVHTi is a useful predictor for significant CoA, but the parameter dPHTi has an improved positive predictive value for detection of significant CoA. Systolic measurements of velocity or pressure half-times are not adequate to assess severity of CoA.

Balloon angioplasty of native aortic coarctation in infants 3 months of age and younger

The use of balloon dilation to treat native aortic coarctation is controversial, particularly in infants. Between January 1991 and September 1996, 12 patients < or = 3 months of age with native coarctation of the aorta (CoA) underwent balloon angioplasty (BA). All 12 lesions were dilated successfully with a mean reduction in peak systolic gradient from 49.3 +/- 16.5 mm Hg to 6.8 +/- 4.0 mm Hg (p < 0.001) and a mean increase in minimum CoA diameter from 2.4 +/- 0.6 mm to 5.5 +/- 1.3 mm (p < 0.001). Intimal flaps or tears were detected immediately after BA in 4 (33%) of 12 patients by angiography and in 8 (89%) of 9 patients by intravascular ultrasonography. No deaths or major complications related to the BA occurred. One patient had documented asymptomatic femoral artery obstruction, and one patient with hydrops fetalis and congenital pleural effusions died with gram-negative sepsis 1 week after the procedure. Follow-up was available for 10 patients (1 was lost to follow-up) between 2 months and 4.1 years (mean 2.4 +/- 1.3 years) after BA. No patient had an aortic aneurysm. Restenosis occurred in 5 (50%) of 10 patients, requiring reintervention a mean of 2.6 +/- 2.1 months after BA. One patient underwent surgical repair. Repeat BAs were performed in the other four patients; three were successful, and one with partial gradient relief required surgical repair. Five patients have not required reintervention a mean of 2.9 +/- 1.0 years after the initial BA. Among these five patients, follow-up intravascular ultrasound performed in three patients a mean of 2.0 +/- 1.9 years after BA showed favorable endovascular remodeling. There was a tendency for early reintervention in patients < 1 month of age and coexistence of a patent ductus arteriosus at the time of BA. In conclusion, selected infants < or = 3 months of age with discrete native CoA may be treated initially with balloon dilation. Most patients who have restenosis respond successfully to repeat BA.

Acute and follow-up intravascular ultrasound findings after balloon dilation of coarctation of the aorta.

The study objective was to examine the vascular wall changes caused by balloon dilation of coarctation of the aorta (CoA) acutely and at short-term follow-up using intravascular ultrasound imaging. Intravascular ultrasound has been valuable in assessing the vessel wall changes in coronary and peripheral arteries after balloon dilation, often with more detail than angiography. Intravascular ultrasound imaging, using 4.8F, 20-MHz or 6.2F, 12.5-MHz catheters on either Diasonics or HP scanners, was performed in 17 patients during balloon angioplasty for native (n = 12) and recurrent (n = 5) CoAs. Nine patients were also studied at the time of follow-up cardiac catheterization 28.1 +/- 18.0 months after angioplasty. Immediately after dilation, the mean pressure gradient across the CoA decreased from 42.9 +/- 16.4 to 9.0 +/- 5.4 mm Hg (P < .001) and the mean diameter of the coarcted segment increased from 4.4 +/- 1.9 to 7.9 +/- 2.4 mm (P < .001). An intimal tear or flap was noted by ultrasound in 12 of the 12 native CoAs and 4 of the 5 recoarctations. In contrast, only 6 of the native CoAs and 2 of the recoarctations had an intimal flap or dissection detected by angiography. At follow-up, the residual pressure gradient did not significantly change from that measured immediately after dilation, but the CoA diameter increased from 7.8 +/- 1.5 to 9.9 +/- 2.3 mm (P < .01). No aneurysms were detected. Four of the 9 patients showed ultrasonic and angiographic evidence of healing and remodeling with diminution in size or disappearance of the intimal tears. There is a high incidence of intimal tears and dissections immediately after balloon angioplasty for native and recurrent CoAs. Intravascular ultrasound is more sensitive than angiography in detecting the vascular wall changes. Even significant intimal tears are not necessarily associated with aneurysm formation, and many decrease in size or disappear at short-term follow-up.

Transluminal balloon coarctation angioplasty: Experience with 27 patients

Transluminal balloon angioplasty (BA) was performed in 27 consecutive patients with coarctation of the aorta (COA), including 7 infants with preductal COA, 7 patients with restenosed COA after surgical repair, and 13 older children and 1 adult with unoperated COA. The patients were 4 days to 27 years old. The balloon was positioned across the COA and inflated sequentially to pressures of 100 and 120 psi, each inflation lasting for 5 to 10 seconds. Peak systolic pressure gradient (PSG) across the COA was recorded and an aortogram was performed before and immediately after BA. PSG also was recorded during follow-up studies performed in 13 patients 3 to 24 months after BA. BA was performed without complications in each patient. Immediately after BA, the mean PSG was reduced from 49 +/- 21 to 10 +/- 7 mm Hg (p less than 0.01), and the mean COA diameter increased from 3.9 +/- 1.4 to 9.6 +/- 3.6 mm (p less than 0.01). After a follow-up period of 3 to 24 months, the mean PSG remained low (15 +/- 11 mm Hg) and the mean COA diameter increased to 10.5 +/- 4.6 mm. BA can be performed safely. It can be a useful palliative treatment in seriously ill infants with COA.