Endovascular stenting for aortic (re)coarctation in adults

A Systematic Review and Meta-analysis on Stenting for Aortic Coarctation Management in Adults

PURPOSE

Endovascular treatment of aortic coarctation (CoA) constitutes a valuable alternative with low morbidity and mortality. The aim of this systematic review and meta-analysis was to assess the technical success, re-intervention, and mortality after stenting for CoA in adults.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement and PICO (patient, intervention, comparison, outcome) model were followed. An English literature data search was conducted, using PubMed, EMBASE, and CENTRAL, until December 30, 2021. Only studies reporting on stenting, for native or recurrent CoA, in adults were included. The risk of bias was assessed using the Newcastle-Ottawa Scale. A proportional meta-analysis was performed to assess the outcomes. Primary outcomes were technical success, intra-operative pressure gradient and complications, and 30-day mortality.

RESULTS

Twenty-seven articles (705 patients) were included (64.0% males, 34.0±13.6 years). Native CoA was present in 65.7%. Technical success was 97% (95% confidence interval [CI], 0.96%-0.99%; p<0.001, I2=9.49%). Six (odds ratio [OR]: 1%; 95% CI, 0.00%-0.02%; p=0.002, I2=0%) ruptures and 10 dissections (OR: 2%; 95% CI, 0.001%-0.02%; p<0.001, I2=0%) were reported. The intra-operative and 30-day mortality were 1% (95% CI, 0.00%-0.02%; p=0.003, I2=0%) and 1% (95% CI, 0.00%-0.02%; p=0.004, I2=0%), respectively. The median follow-up was 29 months. Sixty-eight re-interventions (OR: 8%; 95% CI, 0.05%-0.10%; p<0.001, I2=35.99%) were performed; 95.5% were endovascular. Seven deaths were reported (OR: 2%; 95% CI, 0.00%-0.03%; p=0.008, I2=0%).

CONCLUSION

Stenting for CoA in adults presents high technical success and the intra-operative and 30-day mortality rates were acceptable. During the midterm follow-up, the re-intervention rate was acceptable, and mortality was low.Clinical ImpactAortic coarctation is a quite common heart defect that may be diagnosed in adult patients, as a first diagnosis in native cases or as a recurrent after previous repair. Endovascular management using plain angioplasty has been associated to a high intra-operative complication and re-intervention rate. Stenting in this analysis seems to be safe and effective as is related a high technical success rate, exceeding 95%, with a low intra-operative complication and death rate. During the mid-term follow-up, the re-interventions rate is estimated at less than 10% while most cases are managed using endovascular means. Further analyses are needed on the impact of stent type on endovascular repair outcomes.

Extra-anatomical Bypass in a Case of Recoarctation and Previous Cardiac Surgery

A complex clinical case of aortic recoarctation is presented. The case is a 61-year-old comorbid patient with two previous aortic and cardiac operations. At the age of 10, the patient underwent surgery for post-ductal coarctation of the aorta (adult type) at the typical site, where the stenotic area was completely resected, and an end-to-end anastomosis was performed through a left-sided thoracotomy. Ten years ago, the patient also had mitral valve replacement with a metallic prosthesis due to severe mitral insufficiency, performed via median sternotomy. The patient was admitted to the cardiac surgery unit due to symptoms suggestive of aortic re-stenosis due to status post repair of coarctation of the aorta (resection with end-to-end anastomosis). An extra-anatomic bypass was performed between the ascending and abdominal aorta, with the graft passing through a new diaphragm opening in front of the hilus of the right lung.

Endovascular treatment of aortic coarctation with a novel BeGraft aortic stent in children and young adults: a single-centre experience with short-term follow-up results

OBJECTIVES

We present our experience and outcomes with the BeGraft in the treatment of aortic coarctation in a predominantly paediatric population.

METHODS

This study includes a retrospective analysis of patients who had Begraft aortic stent implantation between 2018 and 2020 from a single centre.

RESULTS

The BeGraft aortic stent was used in 11 patients (7 males, 4 females) with a median age of 14 (13-21) years and a median weight of 65 (46-103) kg. Coarctation was native in five patients and recurrent in six patients. Median stent diameter and length were 16 mm and 38 mm, respectively. The median peak-to-peak pressure was 30 (12-55) mmHg before the procedure and 5 (0-17) mmHg after the procedure. The stenting procedure was successful in 10 of the 11 patients. Stent migration to the abdominal aorta occurred on post-procedure day 1 in the 21-year-old patient, who had previously undergone surgical closure of the ventricular septal defect and balloon angioplasty for coarctation. After repositioning failed, the stent was safely fixed in the abdominal aorta. Strut distortion also occurred during balloon retrieval in one patient, but no aneurysm or in-stent restenosis was observed at 1-year follow-up. The patients were followed for a median of 14 (4-25) months and none required redilation.

CONCLUSIONS

Our initial results demonstrated that the BeGraft aortic stent effectively reduced the pressure gradient in selected native and recurrent cases. Despite advantages such as a smaller sheath and low profile, more experience and medium- to long-term results are needed.

Mid-term outcomes with adult endovascular treatment of coarctation of the aorta

BACKGROUND

This study examines the contemporary medium- and long-term outcomes of endovascular repair of aortic coarctation in the adult.

METHODS

We reviewed the clinical and imaging data of 56 consecutive adult patients with aortic coarctation who underwent endovascular repair at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada, from 2003 to 2018.

RESULTS

There were 20 (35.7%) female and 36 (64.3%) male patients (including 9 re-intervention cases) with a mean age of 33.6 ± 13.6 years. Thirty-seven (66.1%) were treated with balloon-expandable covered stent and 12 (21.4%) were treated with balloon-expandable bare-metal stent. Pressure gradients decreased from baseline level of 27.99 ± 12.75 (8-70) mm Hg to 5.33 ± 4.42 (0-17.5) mm Hg following the procedure. There were 2 (3.6%) procedure related complications (aortic dissection [n = 1] and stent malposition [n = 1]). During a median (Q1 - Q3) follow up of 5.36 (2.28-7.58) years, 2 deaths (4.2%) and 9 (19%) re-interventions occurred, and the overall survival was 95.8%.

CONCLUSION

Percutaneous coarctoplasty, with either covered or bare metal stents, is a safe and durable option for aortic coarctation repair with excellent long-term survival.

Medium-term systemic blood pressure after stenting of aortic coarctation: a systematic review and meta-analysis

OBJECTIVE

Long-term prognosis of patients with coarctation of the aorta (CoA) is impaired due to the high prevalence of hypertension and consequent cardiovascular complications. Although stent implantation results in acute anatomical and haemodynamic benefit, limited evidence exists regarding the late clinical outcome. In this meta-analysis, we aimed to evaluate the medium-term effect of stent placement for CoA on systemic blood pressure (BP).

METHODS

PubMed, EMBASE and Cochrane databases were searched for non-randomised cohort studies addressing systemic BP ≥12 months following CoA stenting. Meta-analysis was performed on the change in BP from baseline to last follow-up using a random-effects model. Subgroup analyses and meta-regression were conducted to identify sources of heterogeneity between studies.

RESULTS

Twenty-six studies with a total of 1157 patients and a median follow-up of 26 months were included for final analysis. Meta-analysis showed a 20.3 mm Hg (95% CI 16.4 to 24.1 mm Hg; p<0.00001) reduction in systolic BP and an 8.2 mm Hg (12 studies; 95% CI 5.2 to 11.3 mm Hg; p<0.00001) reduction in diastolic BP. A concomitant decrease in the use of antihypertensive medication was observed. High systolic BP and peak systolic gradient at baseline and stenting of native CoA were associated with a greater reduction in systolic BP at follow-up.

CONCLUSIONS

Stent implantation for CoA is associated with a significant decline in systolic and diastolic BP during medium-term follow-up. The degree of BP reduction appears to be dependent on baseline systolic BP, baseline peak systolic gradient, and whether stenting is performed for native or recurrent CoA.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

The effectiveness of stenting of coarctation of the aorta: a systematic review

AIMS

Stent placement as treatment for coarctation of the aorta (CoA) has become a more common choice in the last 20 years. Clinical results of CoA stenting are usually reported in small retrospective case series. This systematic review provides an overview of clinical experience with stenting for CoA.

METHODS AND RESULTS

A systematic review of the reports published between January 1990 and December 2014 after stenting a CoA was performed with a focus on relief of obstruction and lowering of blood pressure. Study and patient characteristics were extracted, as well as pre- and post-stenting aortic diameter in mm, systolic pressure gradient (SPG) and pre- and post-stenting systolic blood pressure (mmHg), periprocedural and follow-up complications. Forty-five articles met the inclusion criteria. Three outcomes were extracted from the articles - aortic diameter, systolic pressure gradient and blood pressure. Diameter increased from 6.4 mm (5.6, 7.3) to 15.1 mm (14.5, 15.7), pressure gradients decreased from 40 mmHg (35, 42) to 4 mmHg (3, 5) and systolic blood pressure decreased from 153 mmHg (148, 158) to 132 mmHg (127, 136). Stent migration was the most common periprocedural complication (2.4%), and mortality was low (0.4%).

CONCLUSIONS

Stenting is an effective treatment with regard to immediate relief of obstruction and direct lowering effect on blood pressure. However, there is a lack of evidence regarding late effectiveness concerning durable blood pressure lowering, and limited information on periprocedural and late complications. This observation calls for a systematic and longer prospective follow-up of patients after CoA stenting.

Aortic Coarctation Treated by PTA and Stenting: a Case Presentation and Literature Review

A 13 year-old boy was diagnosed with simple aortic coarctation and a bicuspid aortic valve. Ascending aorta was mildly dilated while aortic arch was smaller, but not hypoplastic. A decision to treat him was made depending on the clinical finding of systemic hypertension in his young age and a baseline trans-stenotic echographic gradient of 48 mmHg. Direct stenting with a covered Cheetham-Platinum balloon-expandable stent was performed with no complications. Despite immediate good angiographic and hemodynamic result with marked decrease of invasively measured gradient, consecutive echographic follow-up demonstrated progressive increase of the gradient in the first 9 months after the index procedure. This resulted in repeated aortic PTA with a larger balloon inside the previously implanted stent-graft. Optimal angiographic result was obtained, the patient remained symptom-free and no antihypertensive therapy was necessary thereafter. Modern treatment of simple aortic coarctation can be done in the cath-lab in appropriately selected cases. Stent implantation should be considered in all cases to avoid dissection and early elastic recoil. Long term follow-up may evidentiate the need for repeated PTA procedures in some cases.

Late hypertension in patients with repaired aortic coarctation

Coarctation of the aorta represents more than a simple obstructive lesion, as there is often evidence of hypertension and vascular dysfunction despite successful surgery at an early age. There are ample data showing that a large proportion of patients develop arterial hypertension, and this appears to increase with age. Our understanding of the pathogenesis of late hypertension is incomplete, and there is limited information on which drugs are most appropriate. Increased arterial rigidity is now well described in this patient group, although it is not known how this should influence therapy. The increase in afterload associated with this increased rigidity has been found to have an impact on the left ventricle at an early stage, and the interaction between the vascular dysfunction and the ventricle is an area of interest and active research. This article reviews some recent studies and highlights areas where research questions remain.

Cheatham platinum stent implantation in children with coarctation of the aorta: single-centre short-term, intermediate-term, and long-term results from Turkey

OBJECTIVES

Our aim was to evaluate patients who were treated by percutaneous stent implantation.

METHODS

Patients with aortic coarctation (n = 35) who had been treated with 38 stents - 12 bare and 26 covered - were evaluated. The demographics and procedural and follow-up data were recorded from hospital registers and compared according to patient specifications, for example, weight and coarctation nature.

RESULTS

The procedure was successful in all patients. There was a statistically significant difference between the patients with native coarctation (n = 17) and those with recurrent coarctation (n = 18) in terms of pre-procedural blood pressures, systolic gradients, coarctation diameters, and the ratio of the coarctation site diameter to the descending aorta diameter. Although all patients received antihypertensive drugs before the procedure, the drug was discontinued in 26 patients during follow-up (p < 0.001). Stent migration was observed in four patients with recurrent coarctation (11.4%), and peripheral arterial injury was seen in three patients (8.5%). The mean follow-up time was 34 ± 16 months. On average, 21 (6-42) months after the procedure, six patients underwent cardiac catheterisation. At least 2 years after the procedure, tomography was performed in 20 patients (57.2%). Patients who were evaluated by multi-slice computerised tomography revealed no pathologies. There was no statistically significant difference between the five patients weighing less than 20 kg and the other 30 patients in terms of demographic and procedural characteristics, procedure success and complication rates, and follow-up data.

CONCLUSION

Stent implantation for aortic coarctation is a method yielding satisfactory results in reducing coarctation gradients, efficient enlargement of the lesion area, and resolution of hypertension for children, including those weighing less than 20 kg.

Procedural Outcome and One Year Follow up of Patients Undergoing Endovascular Stenting for Coarctation of Aorta: A Single Center Study

INTRODUCTION

Coarctation of aorta is the fourth most common cardiac lesion requiring intervention. While surgery used to be the only treatment option, endovascular intervention is now considered the first option in simple coarctation lesions. Despite increased popularity, there are currently no FDA approved stents for use in coarctation of aorta and data on the outcome of this procedure is still sparse.

METHODS

Between October 2004 and June 2010, 33 patients who underwent treatment with Cheatham-Platinum stents for coarctation of aorta were retrospectively studied. All the patients underwent control CT scans at 6 month and echocardiography at 1 year follow-up.

RESULTS

There were 17 females and 16 males with a mean age of 26.64 ± 16.30 years (range 2-71 years). The mean stent length and balloon diameter were 3.18 ± 0.56 mm and 15.7 ± 3.12 mm respectively. We achieved an immediate success rate of 96.9% with the only complication of aortic rupture which led to our single mortality in this series. At 6 month follow up no complications were noted in the CT scans. The mean echocardiographic aortic arch gradient at one year follow up was 21.73 ± 11.06 mmHg.

CONCLUSION

This study is one of the few cohorts of patients with stenting for coarctation of aorta in Iranian population which comprised a diverse group of patients from early childhood to elderly. It was demonstrated in this study that stenting for coarctation of aorta is a safe and effective procedure if done carefully and performed in selected patients.

Coarctation of the aorta: nonsurgical treatment using stent implantation

INTRODUCTION

Coarctation of the aorta (CoA) accounts for 5%-8% of all congenital heart defects. If left untreated, most patients with significant CoA will have varying degrees of morbidity (e.g. hypertension, stroke, collateral formation and ventricular hypertrophy), possibly even mortality. Traditionally, treatment for this condition is surgical. Herein, we report stenting during catheterisation as an alternative nonsurgical treatment option for patients with CoA, and present the treatment outcomes of patients who underwent this treatment option.

METHODS

We retrospectively reviewed four patients (2 men and 2 women; age range 20-41 years) who underwent CoA stenting under general anaesthesia for the treatment of native CoA or restenosis of CoA at our institution. Three patients had a 40-mm Palmaz stent inserted, while one had a 39-mm Cheatham-Platinum covered stent inserted. Angiography and measurement of pressure gradients were performed before and after stent implantation to ensure good treatment outcomes.

RESULTS

The patients' treatment outcomes were good, with a significant reduction in pressure gradients across the narrowed segments. Angiography showed relief of CoA. The patients were followed up for 1-3 years, during which no complications were noted.

CONCLUSION

This is the first reported series in Singapore on the nonsurgical treatment of CoAs in adult patients using stents during interventional cardiac catheterisation. This less invasive procedure may lead to a new paradigm shift with regard to the treatment of CoA.

Comparison between covered and bare Cheatham-Platinum stents for endovascular treatment of patients with native post-ductal aortic coarctation: immediate and intermediate-term results

OBJECTIVES

This study sought to evaluate the outcomes of endovascular treatment with covered versus bare Cheatham-platinum stents (NuMed, Hopkinton, New York) in coarctation of aorta (CoA) patients.

BACKGROUND

Covered stenting has been newly recognized as a useful therapeutic method for patients with native CoA, but there has been no study comparing the use of covered stents with bare stents for treating CoA.

METHODS

In this randomized clinical trial, 120 patients with a mean age of 23.60 ± 10.99 years (range 12 to 58 years, 79 men), with post-ductal, short-segment, severe native CoA underwent implantation of bare Cheatham-Platinum (bCP) (n = 60) or covered Cheatham-Platinum (cCP) (n = 60) stents. Patients were followed clinically at 1, 3, 6, and 12 months after the stenting and yearly thereafter. During follow-up, multislice computed tomography (64 slices) was scheduled to assess any complications.

RESULTS

The procedural success rate was 100% in both groups. Patients were followed for 31.1 ± 19.2 months. Although recoarctation was seen only in the bCP group during follow-up, the difference between groups did not reach statistical significance (6.7% vs. 0%; p = NS). Two cases of pseudoaneurysm (3.3%) occurred in the cCP group, but none was observed in the bCP group (p = NS). Normotensive status significantly increased during follow-up in both groups (from 15% to 73.3% in the bCP group and 16.7% to 78.3% in the cCP group, p < 0.001 for each group and not significant between groups).

CONCLUSIONS

Implanting bCP and cCP stents have very high success rates with remarkable hemodynamic effects in severe native CoA patients. Patients undergoing cCP stent implantation experienced a nonsignificantly lower recoarctation rate and a higher occurrence of pseudoaneurysm formation with respect to bCP stenting during follow-up. These findings indicate that CoA stenting is a safe procedure. (Endovascular Stenting With Covered CP Stent Compared With Bare CP Stent for Adult Patients With Coarctation: The Initial and Intermediate-Term Follow-Up Results; IRCT201012045311N1).

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.).