Covered Cheatham-platinum stents for aortic coarctation: early and intermediate-term results

Five-Year Outcomes of Coarctoplasty with Stents in the Pediatric Population: Results from a Retrospective Single-Center Cohort with Centrally Adjudicated Outcomes

Transcatheter stent implantation is a widely performed procedure for treating native coarctation of the aorta (CoA) in pediatric patients. However, data on mid- to long-term outcomes are limited. The aim of this study was to evaluate the mid-term safety and efficacy of transcatheter CoA stenting based on centrally adjudicated outcomes. This retrospective cohort study included patients aged 15 years or younger undergoing de novo stenting for CoA or recoarctation (reCoA) between 2006 and 2017. Immediate and 5-year outcomes were assessed. Immediate outcomes (procedural and in-hospital) were retrieved from electronic records. Rates of 5-year reCoA, stent fractures, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were mid-term outcomes. The study included 274 patients (64% male and 36% female) with a median (interquartile range) age of 9 (6-12) years. Procedural success was achieved in 251 patients (91.6%). Procedural complications occurred in 4 patients (1.4%), consisting of stent migration in 1 (0.3%) and small non-expanding non-flow-limiting aortic wall injuries in 3 (1.1%). Major vascular access complications were observed in 18 patients (6.6%), acute limb ischemia in 8 (2.9%). In-hospital mortality occurred in 4 patients (1.4%). Five-year cumulative incidence rates of stent fractures, reCoA, and aortic aneurysmal/pseudoaneurysmal formation were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Of 73 reCoAs, 47 were treated with balloon angioplasty, and 15 underwent a second stent implantation. Five-year all-cause mortality occurred in 4/251 (1.6%) patients. Coarctoplasty with stents was safe and effective in our pediatric population during a 5-year follow-up despite a high rate of reCoA.

Endovascular treatment of aortic coarctation using covered balloon-expandable stents-a systematic review and meta-analysis

Objectives

Balloon dilation followed by balloon-expandable stent implantation is an effective treatment for improving hemodynamic status in patients with coarctation of the aorta (CoA). However, limited evidence exists regarding the safety and efficacy of covered balloon-expandable stents (CBSs) in a large cohort. In this meta-analysis, we aimed to evaluate the overall success rates, hemodynamic and anatomical benefits, complications, and mid-term results of CBSs in treating CoA.

Methods

The PubMed, Embase, and Cochrane Library databases were systemically searched for studies reporting outcomes of CBSs in treating CoA. Single-group rate meta-analyses were performed to calculate estimated pooled procedural success rates, the incidence of complications, and re-coarctation rates. A meta-analysis using standardized mean differences was conducted to compare pre- and postoperative trans-coarctation pressure gradients (PGs), coarctation diameter, and overall changes in systolic blood pressure (SBP). Subgroup analyses were performed to identify potential sources of heterogeneity.

Results

The final analysis included 12 studies with a total of 411 patients. The estimated pooled procedural success rate was 100% [95% confidence interval (CI): 98%-100%, I2 = 0, P = 0.78]. Significant decreases in trans-coarctation PGs and SBP were observed. The pooled incidences of stent-related, aortic, and access site complications were 2% (95% CI: 0%-5%, I 2 = 30.4%, P = 0.15), 2% (95% CI: 0%-4%, I 2 = 0%, P = 0.76), and 3% (95% CI: 1%-7%, I 2 = 52.9%, P = 0.02), respectively. Subgroup analyses showed that implantation of BeGraft stents was related to a significantly higher incidence of access site complications.

Conclusion

Covered balloon-expandable stent implantation in treating CoA is safe and effective with high procedural success rates, an acceptable incidence of complications, and a low incidence of re-coarctation.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO (CRD42023430356).

Endovascular Repair Blunt Thoracic Aortic Injury in Adolescent: A Case Series

BACKGROUND

Blunt traumatic aortic injury (BTAI) is a rare occurrence in adolescents, yet it is associated with a high mortality rate necessitating immediate treatment. Although endovascular repair has become the preferred treatment for such injuries in adults, its effectiveness in adolescents remains uncertain.

CASE SUMMARY

Blunt traumatic aortic injury typically presents with concomitant injuries to other organs and carries a high perioperative mortality rate with operative repair (OR). In this report, we describe the treatment of 3 clinical cases of BTAI in adolescents using thoracic endovascular aortic repair (TEVAR). These cases contribute pertinent evidence supporting the efficacy of intravascular repair for BTAI.

CONCLUSION

Operative repair (OR) remains the gold standard for treating BTAI in adolescents. Nevertheless, TEVAR therapy presents a viable alternative for patients with multiple injuries in whom anticoagulation is contraindicated. Further long-term observation is necessary to assess the lasting effects of TEVAR therapy.

CLINICAL IMPACT

This study has provided insights into endovascular repair for adolescent BTAT, offering clinicians significant reference material for choosing treatment strategies for adolescent BTAT. The study aims to demonstrate the safety and effectiveness of endovascular repair treatments in a series of clinical cases involving adolescent BTAI.

Very long-term follow-up after aortic stenting for coarctation of the aorta

INTRODUCTION AND OBJECTIVES

Stent implantation is the preferred treatment in older children and adults with aortic coarctation (CoA). We aimed to determine the incidence of very late events after CoA stenting.

METHODS

We analyzed a cohort of CoA patients who underwent stent implantation at our center between 1993 and 2018. Patients were periodically followed up in outpatient clinics, including computed tomography (CT) and fluoroscopy assessment.

RESULTS

A total of 167 patients with CT and fluoroscopy data were included: 83 (49.7%) were aged ≤ 12 years and 46 (28%) were female. The mean clinical follow-up time was 17±8 (range 4-30) years and the mean time to CT/fluoroscopy was 11±7 years. Aortic aneurysm was present in 13% and was associated with the PALMAZ stent (OR, 3.09; 95%CI, 1.11-9.49; P=.036) and the stented length (OR, 0.94; 95%CI, 0.89-0.99; P=.039). Stent fracture was frequent (34%), but was not related to the presence of aneurysm. Stent fracture was associated with young age (OR, 3.57; 95%CI, 1.54-8.33; P=.003), male sex (OR, 4.00; 95%CI, 1.51-12.5, P=.008) and inversely with the PALMAZ stent (OR, 0.29; 95%CI, 0.12-0.67, P=.005). Reintervention was lower in adults (10%), mainly related to aneurysms. Those treated when aged ≤ 12 years had higher reintervention rates (43%) due to recoarctation somatic growth.

CONCLUSIONS

This long-term follow-up study of CoA patients treated with stenting revealed a significant incidence of late events. Reintervention rates were higher in patients treated at younger ages. Periodic imaging surveillance appears to be advisable.

Long-term follow-up after endovascular treatment of aortic coarctation with bare and covered Cheatham platinum stents

BACKGROUND

Endovascular treatment of aortic coarctation (CoA) in children and adults frequently requires stent implantation. The aim of this study was to analyze long-term results after CoA treatment with bare and covered Cheatham-PlatinumTM (CP) stents in our institution and to derive recommendations for the differential use of these stent types.

METHODS

In this retrospective single institution study, 212 patients received endovascular CoA treatment with bare (n = 71) and covered (n = 141) CP stents between September 1999 and July 2021, respectively. The indications for treatment were native CoA in 110/212 patients (51.9%) and re-coarctation after primary surgical or interventional treatment in 102/212 patients (48.1%). Median patient age at endovascular CoA treatment was 18.8 years [IQR 11.9; 35.8]. Long-term follow-up was available in 158/212 patients (74.5%) with a median follow-up of 7.3 years [IQR 4.3; 12.6].

RESULTS

Procedural success was achieved in 187/212 (88.2%) patients. Survival rate was 98.1% after 5, and 95.6% after 10 and 15 years, respectively. The probability of freedom from re-intervention was 93.0% after 5, 82.3% after 10 and 77.8% after 15 years, respectively. Freedom from re-interventions (44/158, 27.8%) did not differ between patients who received bare or covered CP stents (p = 0.715). Multivariable risk factor analysis identified previous CoA surgery (HR: 2.0, 95% confidence interval (CI): 1.1-3,9, p = 0.029), postdilatation (HR: 2,9, 95% CI: 1.1-6.3, p = 0.028) and age at intervention (HR: 0.96, 95% CI: 0.94-0.99, p = 0.002) as independent risk factors for re-intervention. Peri-procedural complications occurred in 15/212 (7.1%) patients (dissection/thrombosis of vascular access vessel: n = 9; bleeding: n = 1; stent dislocation: n = 2; aortic dissection/aortic wall rupture: n = 3). Long-term complications were observed in 36 patients and included stent fracture (n = 19), aneurysm formation (n = 14), endoleak (n = 1) and subclavian artery stenosis (n = 2). Peri-procedural and long-term complications did not differ between patients who received CoA treatment with bare or covered CP stents (all p > 0.05).

CONCLUSION

Endovascular treatment of CoA using bare or covered CP stents can be performed safely and effectively with excellent long-term results. Survival, re-intervention and complication rate did not significantly differ between both stent types. However, individual stent selection is advisable with regard to CoA morphology and severity as well as patient age.

Early outcomes of the treatment of aortic coarctation with BeGraft aortic stent in children and young adults

We report our experience and early outcomes of using the BeGraft aortic stent in children, adolescents, and young adults. BeGraft aortic stent (Bentley InnoMed, Hechingen, Germany) requires a smaller long sheath compared to other covered stents, and it has a low profile and adequate radial power. With these features, it can overcome some limitations in the treatment of coarctation, especially in children. This is a single centre retrospective analysis of 11 implanted BeGraft aortic stents in coarctation of the aorta between July 2020 and November 2021. The eleven stents were successfully implanted in 11 patients (10 males). The median age of the patients was 13.7 years (interquartile range 12-16 years), and the median weight was 43 kg (interquartile range 35-62 kg). In five patients, after the stents were opened completely by the first balloon, they were exchanged with a Z-MED II™ balloon, 1-3 mm larger in diameter, and the stents were redilated. The median catheter-derived systolic peak-to-peak pressure gradient was 23 mm Hg (interquartile range 16-37 mmHg) before the procedure and 3 mm Hg (interquartile range 1-5 mm Hg) after the procedure. Except for the partial femoral artery thrombosis in two patients, no other procedural complications were observed in our study. The median follow-up duration was 5 months (interquartile range 2-12 months). During follow-up, only one patient (9%) had stent narrowing that required dilation. Our initial results and short-term follow-up showed that the BeGraft aortic stent implantation and redilation can be performed effectively, safely, and successfully in the treatment of coarctation of the aorta.

Transient Recurrent Laryngeal Nerve Palsy after Interventional Therapy

BACKGROUND

 Hoarseness due to laryngeal nerve injury is a known complication after cardiothoracic surgery involving the aortic arch. However, this complication is only rarely reported after catheter interventions.

RESULTS

 In this article we present the unusual case of a left-sided vocal cord paralysis in four patients after primary stenting of a re-coarctation, re-dilatation of a stented coarctation, a primary stenting of the left pulmonary artery (LPA), and prestenting for percutaneous pulmonary valve implantation with dilation of the LPA. After implanting bare metal stents, it is common practice, whilst contemplating the diameters of the adjacent structures, to optimize the stent diameter in a two-step procedure and dilate the stent until a maximum diameter is achieved and there is no residual gradient after applying this technique. Four of our patients experienced hoarseness after the intervention and a vocal cord paralysis was diagnosed. Angiography revealed no signs of extravasation or dissection. Clinical symptoms improved over the course of the following 6 months; patients with interventions at the aortic arch showed a complete remission, patients with procedures involving the LPA showed only mild regression of the symptoms.

CONCLUSION

 To our knowledge, this complication (Ortner's syndrome, cardiovocal syndrome) after such interventions has rarely been reported before. Although a rare complication, the recognition of these symptoms may support colleagues in managing affected patients. In addition, awareness for hoarseness after interventional therapies and systematic screening for this complication might help to identify patients at risk in the future.

Evaluating the Effectiveness of Stenting for Aortic Coarctation

BACKGROUND

 Coarctation of the aorta (CoA) is a congenital cardiovascular malformation involving narrowing of the thoracic aorta just distal to the left subclavian artery. The aim of our study was to evaluate the hemodynamic effects of endovascular treatment for CoA by using invasive aortic catheterization.

METHODS

 All patients with CoA who underwent treatment by aortic stent implantation between September 1, 2003, and February 1, 2019, at the "Onassis Cardiac Surgery Center," in Athens, Greece, were evaluated. Patients were treated with either bare (uncovered) Cheatham-Platinum (bCP) or covered Cheatham-Platinum (cCP) stent implantations. Invasive aortic pressure measurements were recorded before and after the endovascular intervention.

RESULTS

 A total of 48, eight zig CP stents, comprising 24 bCP and 24 cCP stents were implanted in 47 patients. The mean aortic diameter (mm) at the CoA lesion increased from 9.7 ± 3.3 to 19.2 ± 2.9 mm (p <0.01) after the endovascular procedure. The invasive mean blood pressure (BP; mm Hg) from catheterization in the descending aorta increased (before = 114.2 ± 12.8 vs. after = 135.5 ± 28.1; p <0.01), while the invasive mean BP (mm Hg) from catheterization in the ascending aorta was decreased (before = 156.8 ± 25.0 vs. after = 138.4 ± 27.5; p <0.01) after the intervention. The mean aortic BP gradient decreased in both types of stents after intervention (BP gradient among patients with cCP stents = 30.9 +/- 23.6 mmHg and BP gradient among patients with bCP stents = 38.0 +/-23.1 mmHg). However, there was no statistically significant difference between the two types of stents; p = 0.36.

CONCLUSIONS

 Invasive aortic catheterization provided evidence that endovascular stenting with either bare or covered stents is efficient in treating patients with CoA.

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.

Covered Stents in the Management of Aortic Coarctation and Right Ventricular Outflow Tract Obstruction

PURPOSE OF REVIEW

To review the use of covered stents in the treatment of coarctation of the aorta (CoA) and right ventricle to pulmonary artery (RV-PA) conduit obstruction.

RECENT FINDINGS

The only commercially available covered stent approved for treatment of CoA and dysfunctional RV-PA conduits is the covered Cheatham-Platinum stent (CCPS). Early outcomes have demonstrated its safety and have suggested its efficacy in treating or preventing aortic wall injury (AWI) or conduit disruption. A recent study of CCPS use for CoA reported a progressive risk of stent fracture over time and a risk of AWI despite the purported protection that the CCPS provides. The use of other covered stents has been reported, but large, systematic studies are lacking. CCPS use may reduce but does not eliminate the risk of conduit disruption or AWI. Structural limitations of the CCPS may predispose it to stent fracture. Access to a broad range of covered stents continues to be an unmet need in the field of congenital interventional cardiology.

Covered Cheatham-Platinum Stent for Treatment of Descending Thoracic Aortic Stenosis Caused by Takayasu Arteritis in Two Children

Takayasu arteritis (TA) is a chronic type of systemic large vessel vasculitis, mainly involving the aorta and its main branches. Both surgical and endovascular revascularization are effective methods for treating TA-related stenosis of the aorta and its branches. By December 2020, there have been very limited reports on the use of coated Cheatham-Platinum (CP) stents in the treatment of TA associated descending thoracic aortic stenosis. Two children with thoracic aortic stenosis caused by TA who received the covered CP stent in Xuanwu Hospital of Capital Medical University were reported. The follow-up time was 1.5 years and 4 years, respectively. The covered cheatham-platinum (CP) stent may be an alternative treatment for TA associated children with descending aortic stenosis.

Covered stent placement for treatment of coarctation of the aorta: immediate and long-term results

OBJECTIVES

This study aimed to describe the safety and efficacy of covered stents in patients with coarctation of aorta (CoA) for immediate and long-term follow-up.

BACKGROUND

Covered stents are increasingly being used in (re)CoA, mainly to reduce the risk of aortic wall injuries (AWI). However, limited data are available on intermediate and long-term outcome.

METHODS

In 89 patients (67.4% male) with a mean age of 23.9 ± 15.8 (min max range 5.1-71.6) years were 102 covered stents implanted (January 2003 - December 2017). Short-term pre/post-implant hemodynamics and angiographic data were reported. Changes in blood pressure, the use of antihypertensive drugs and complications were recorded during follow-up.

RESULTS

The procedural success rate was 100%. The mean invasive ascending-to-descending aorta systolic gradient under general anaesthesia decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After a mean follow-up time of 6.6 ± 3.7 years, there was a persistent improvement of the mean systolic blood pressure gradient between right arm and leg (-7 ± 18 vs 38 ± 24 mmHg; p < 0.001). A larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017) and needed ≥ 2 drugs (20.2% vs 27.4%, p = 0.066) to control blood pressure. Long-term adverse events were found in 4.5% of patients [covered stent fracture (n = 3), aneurysm formation (n = 2)].

CONCLUSIONS

Covered stent implantation for CoA is highly successful, safe and results in a persistent hemodynamic improvement in the immediate and long-term outcome. Lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain favourable hemodynamic results after stenting.

CONDENSED ABSTRACT

Long-term follow-up data on covered stents in patients with coarctation of the aorta are scarce. A cohort of 89 patients was reviewed. The procedural implantation success rate was 100%. The invasive gradient decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After follow-up of 6.6 ± 3.7 years, there was a persistent improvement of the clinical systolic blood pressure gradient (-7 ± 18 vs 38 ± 24 mmHg; p < 0.001). However, a larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017). Covered stent implantation results in favourable hemodynamic effects, but lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain these results.

Mechanical properties of low-diameter balloon expandable covered stents

OBJECTIVES

To determine over-dilation potential of commercially available covered stents.

BACKGROUND

Covered stents including the Atrium iCast, Gore VBX, and Lifestream stents (LS) can treat ruptures, dissections, and aneurysms in small vessels. Especially in growing patients, stents often require serial dilations beyond their implant or nominal diameters. Tolerance of serial dilations is clinically important information for interventionalists.

METHODS

Serial dilations of 5-12 mm iCast, VBX, and LS covered stents were performed in 1-2 mm increments (up to 20 mm). With each dilation, foreshortening and recoil were measured, and stent strut and covering integrity were assessed. High-pressure balloons were used to expand the stents until they fractured or could not be further expanded.

RESULTS

The 5-8 mm LS tolerated dilation to 14.5-16 mm. The 10-12 mm LS stents tolerated dilation to 18 mm and fractured on the 20 mm balloon. LS stents foreshortened 35%-45% on average after 8 mm of over-dilation and had 5%-10% recoil on <6 mm over-dilation. All iCast stents tolerated dilation to 12-13 mm and required fracture for dilation to >14 mm. ICast stents foreshortened 19%-29% at maximum dilation, with 3-6% recoil on <2 mm over-dilation, and < 3% thereafter. VBX stents over-dilated to 2.9-4.7 mm above nominal, foreshortening 40%-50% after 4-6 mm of over-dilation before collapsing into a ring. VBX stent recoil was <2.5% on all dilations.

CONCLUSIONS

LS stents had the greatest over-dilation potential. VBX stents had the least recoil but tended to foreshorten significantly 3-4 mm above nominal. Regardless of nominal size, all iCast stents (including the 5 mm) tolerated dilation to a maximum of 12-13 mm.

Operative Traumatic Aortic Injuries at an Urban Pediatric Hospital

PURPOSE

Limited data are available describing the long-term results of pediatric patients undergoing aortic repair secondary to trauma. Therefore, this descriptive investigation was completed to abrogate this deficit.

METHODS

A retrospective review of an urban level 1 pediatric trauma database maintained at a high-volume dedicated children's hospital between 2008-2018 was completed to capture all cases of severe traumatic aortic injury and associated demographics, mechanisms, injury severity, treatment, and clinical outcomes.

RESULTS

In the prespecified interval, 2189 children (age <18 years) presented to our facility as a level 1 trauma activation. Of these cases, a total of 10 patients (.5%) had a demonstrable thoracic or abdominal aortic injury. The mean age of our study cohort was 10.4 ± 5.7 years. The mechanism of injury consisted of 8 participants involved in motor vehicle accidents, 1 pedestrian struck by a vehicle, and 1 struck by a falling boulder. Injuries were identified via CT angiogram (n = 9) or autopsy (n = 1) and consisted of 6 thoracic aortas and 4 abdominal aortas. The mean trauma injury severity score was 37.6 ± 19.9. Seven of the patients underwent open surgical intervention, 1 underwent endovascular intervention, 1 was treated with medical management, and 1 patient expired in the trauma bay before surgery could be performed. Aortic pathologies observed were 6 transections, 2 dissections, and 2 occlusions. Five of the ten patients underwent nonaortic surgical procedures. To determine operative outcomes, we excluded the 2 patients who did not receive aortic intervention. In the 8 remaining patients, the mean hospital length of stay was 12.8 ± 4.8 days with 6.8 ± 4.1 days in the intensive care unit. All 9 participants who survived the initial trauma evaluation were discharged from the hospital. Mean follow-up was 38.3 ± 43.0 months; during which, we observed no additional aortic-related morbidity, mortality, and reinterventions. The only stent-graft deployed remained in stable position without evidence of endoleak or migration by duplex.

CONCLUSION

Traumatic aortic injury is exceedingly rare in children and primarily of blunt etiology. Of the patients who survive the scene, operative repair seems to be associated with excellent perioperative and long-term survival.

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.

Highly Conductive Collagen by Low-Temperature Atomic Layer Deposition of Platinum

In modern biomaterial-based electronics, conductive and flexible biomaterials are gaining increasing attention for their wide range of applications in biomedical and wearable electronics industries. The ecofriendly, biodegradable, and self-resorbable nature of these materials makes them an excellent choice in fabricating green and transient electronics. Surface functionalization of these biomaterials is required to cater to the need of designing electronics based on these substrate materials. In this work, a low-temperature atomic layer deposition (ALD) process of platinum (Pt) is presented to deposit a conductive thin film on collagen biomaterials, for the first time. Surface characterization revealed that a very thin ALD-deposited seed layer of TiO₂ on the collagen surface prior to Pt deposition is an alternative for achieving a better nucleation and 100% surface coverage of ultrathin Pt on collagen surfaces. The presence of a pure metallic Pt thin film was confirmed from surface chemical characterization. Electrical characterization proved the existence of a continuous and conductive Pt thin film (∼27.8 ± 1.4 nm) on collagen with a resistivity of 295 ± 30 μΩ cm, which occurred because of the virtue of TiO₂. Analysis of its electronic structures showed that the presence of metastable state due to the presence of TiO₂ enables electrons to easily flow from valence into conductive bands. As a result, this turned collagen into a flexible conductive biomaterial.

Closure of an unusual morphology patent ductus arteriosus with a covered stent in a dog

Patent ductus arteriosus (PDA) with unusual morphology was diagnosed in a 3-year-old German shepherd presented for exercise intolerance. Two interventional PDA closure procedures with various Amplatzer devices and one surgical ligation were attempted to close the PDA. However, PDA closure failed with both methods due to the unusual morphology and the severe enlarged ductus ampulla. Therefore, the patient underwent an aortic covered stent placement, and successful closure of the PDA was achieved. Eight months after the procedure, the dog was free of clinical signs and no residual flow was identified through the PDA on transthoracic echocardiography. Moreover, computed tomography angiography demonstrated correct stent positioning, with no evidence of thrombus formation, damage to the stent, nor any aortic wall abnormalities. Aortic covered stent placement is a viable option in dogs with unusual PDA morphology.

Early and late outcome of covered and non-covered stents in the treatment of coarctation of aorta- A single centre experience

Objective

Stenting of coarctation of aorta with covered or uncovered stents is the accepted modality of treatment in older children and adults. The indications which mandate the use of covered stents are still unclear. We attempted to study the early and late outcomes after stenting of native and recurrent coarctation of aorta with uncovered and covered stents.

Method

This is a retrospective study of patients who underwent stenting for coarctation of aorta with covered or non-covered stents at our institute. Early and late outcome for both the groups were studied.

Results

Twenty patients underwent implantation of covered stent and twenty five patients had uncovered stent implantation. Patients in the covered stent group were older and had greater basal pressure gradient. More patients in the covered stent group had residual gradient >10 mm Hg after the procedure. There was no mortality or aortic wall injury in either group. Four patients in the covered stent group underwent planned re-intervention and two had unplanned re-intervention. None of the patients in the uncovered stent group had re-intervention. Higher incidence of late lumen loss was noted in the covered stent group.

Conclusion

Uncovered stents can be safely implanted with minimal risk of aortic wall injury in patients with low risk anatomic features. Covered stent implantation is associated with higher incidence of planned and unplanned re-intervention.

Immediate results of percutaneous management of coarctation of the aorta: A 7-year single-centre experience

BACKGROUND

Coarctation of the aorta (CoA) is often treated percutaneously. The aim of this study was to describe the immediate results of percutaneous management of native aortic coarctation (NaCoA) and recoarctation of the aorta (ReCoA) at our institution.

METHODS

We identified all patients with NaCoA or ReCoA who underwent percutaneous dilatation by either balloon angioplasty (BAP) or endovascular stent implantation (ESI) between 2011 and 2017. Success was defined as a residual peak-to-peak gradient (PPG) <20 mmHg or a ≥50% reduction in the gradient if the pre-intervention PPG was <20 mmHg.

RESULTS

63 patients (median age 6.8 years, interquartile range [IQR] 0.4-14.2) were identified. Among 11 patients with NaCoA, 7 underwent BAP and 4 had ESI, and among 52 patients with ReCoA, 42 underwent BAP and 10 had ESI. In patients with NaCoA, BAP was successful in 71%, with median PPG decreasing from 32 mmHg (IQR 25-46) to 17 mmHg (IQR 4-23) (p = .02), and ESI was successful in 100%, with median PPG decreasing from 20 mmHg (IQR 14.5-40) to 2 mmHg (IQR 0-6) (p < .01). In patients with ReCoA, BAP was successful in 69%, with median PPG decreasing from 20 mmHg (IQR 16-31.3) to 9 mmHg (IQR 0-14.3) (p < .001), and ESI was successful in 100%, with median PPG decreasing from 18 mmHg (IQR 11.5-22.8) to 0 mmHg (IQR 0-3.5) (p < .01). ESI was more successful than BAP (p = .01). There was only one complication.

CONCLUSIONS

Percutaneous management of CoA is safe and effective in both NaCoA and ReCoA. Stent implantation is more effective than BAP.

Aortic Coarctation

Aortic coarctation is a discrete narrowing of the thoracic aorta. In addition to anatomic obstruction, it can be considered an aortopathy with abnormal vascular properties characterized by stiffness and impaired relaxation. There are surgical and transcatheter techniques to address the obstruction but, despite relief, patients with aortic coarctation are at risk for hypertension, aortic complications, and abnormalities with left ventricular performance. This review covers the etiology, pathophysiology, diagnosis, and management of adults with aortic coarctation, with emphasis on multimodality imaging characteristics and lifelong surveillance to identify long-term complications.

Management of adults with coarctation of aorta

Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Prediction of post-stenting biomechanics in coarcted aortas: A pilot finite element study

Endovascular stenting has recently become a standard treatment for native coarctation of the aorta (CoA) in children and young adults, given the efficacy in relieving vessel obstruction with a low incidence of adverse events. Yet, despite the short-term success of the technique, late hypertension remains an endemic risk. To assess the impact of the percutaneous procedure on the aortic wall biomechanics, we designed a novel finite element (FE) protocol for the simulation of endovascular stenting in three patient-specific CoA anatomies, developing a remeshing procedure that allows for coping with different CoA severities. Our FE protocol was able to yield numerical results on stent distortions and stresses, as well as on changes in aortic wall stresses and distensibility. These results were consistent with intraprocedural in-vivo evidences and with previous findings from the literature, and they suggest that our numerical approach could be used to understand the role of patient specific anatomical features (CoA severity and arch type) on the post-stenting aortic biomechanics. If soundly validated on a vast cohort of patients, our approach could support patient selection for the procedure.

Coarctation: A Review

Coarctation of the aorta occurs in 0.04% of the population, and accounts for approximately 10% of lesions in adults with congenital heart disease. It can occur as an isolated lesion or as a part of a complex defect, and is most commonly associated with bicuspid aortic valve, ventricular septal defect, and mitral valve abnormalities. Since the first surgical repair in 1944, the available treatment options have expanded greatly. Perhaps one of the most important advances in the management of coarctation of the aorta has been the development of transcatheter therapy for both native and especially recurrent coarctation of the aorta. Late complications, even after apparently successful treatment, are not uncommon. For this reason, lifelong follow-up is vital.

Comprehensive assessment of mechanical behavior of an extremely long stent graft to control hemorrhage in torso

Traumatic vascular injuries, resulting from either civilian accidents or wounded soldiers, require new endovascular devices (i.e., stent graft) to rapidly control the excessive internal hemorrhage in torso region. Current stent designs are limited by their permanent nature, which is note well suited for emergent placement. A retrievable stent graft could regulate the internal bleeding temporarily, as fast as possible with the most feasible performance, until the patients arrive the hospital to receive the proper treatment. The novel endovascular device of this study is designed according to the anatomy of a porcine model with plans to transition to a human model in the future. The stent graft is manufactured using a substantially long nitinol backbone and covered selectively based on anatomic measurements, with highly stretchable expanded-polytetrafluoroethylene (ePTFE). In this study, our group comprehensively explored designing and manufacturing methods, and their impact on the stent graft performance. Geometric parameters and heat treatment conditions were investigated to show their effect on the radial force of the metallic backbone. As a retrievable device, the resistance force for retrieval as well as deployment were measured, and analyzed to be manipulated through ePTFE covering configurations. In vitro measurements for bleeding were measured using swine aorta to show the functionality of the stent graft under the simulated pulsatile flow circulation. Finally, the stent graft showed substantial effectiveness for hemorrhage control in vivo, using swine model. The new design and fabrication methods enable rapid hemorrhage control that can be removed at the time of a dedicated surgical repair.

Chetham-platinum-covered stent, aortic coarctation, and left subclavian artery: sometimes is there one too many?

A new approach was used in the percutaneous treatment of two patients with severe recoarctation involving the origin of the left subclavian artery. A tiny handmade fenestration was created in a NuMED-covered Cheatham-platinum stent before its implantation to avoid left subclavian artery occlusion. The stent placement was performed using a two-guidewire technique in which the different stiffness helped a proper positioning of the stent. After the stent deployment, the fenestration was enlarged performing a balloon angioplasty to improve flow in left subclavian artery.

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.

Biocompatibility of common implantable sensor materials in a tumor xenograft model

Real-time monitoring of tumor microenvironment parameters using an implanted biosensor could provide valuable information on the dynamic nature of a tumor's biology and its response to treatment. However, following implantation biosensors may lose functionality due to biofouling caused by the foreign body response (FBR). This study developed a novel tumor xenograft model to evaluate the potential of six biomaterials (silicon dioxide, silicon nitride, Parylene-C, Nafion, biocompatible EPOTEK epoxy resin, and platinum) to trigger a FBR when implanted into a solid tumor. Biomaterials were chosen based on their use in the construction of a novel biosensor, designed to measure spatial and temporal changes in intra-tumoral O2 , and pH. None of the biomaterials had any detrimental effect on tumor growth or body weight of the murine host. Immunohistochemistry showed no significant changes in tumor necrosis, hypoxic cell number, proliferation, apoptosis, immune cell infiltration, or collagen deposition. The absence of biofouling supports the use of these materials in biosensors; future investigations in preclinical cancer models are required, with a view to eventual applications in humans. To our knowledge this is the first documented investigation of the effects of modern biomaterials, used in the production of implantable sensors, on tumor tissue after implantation. © 2018 The Authors. Journal of Biomedical Materials Research Part B: Applied Biomaterials published by Wiley Periodicals, Inc. J Biomed Mater Res Part B, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1620-1633, 2019.

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.

Endovascular repair of severe aortic coarctation, transcatheter aortic valve replacement for severe aortic stenosis, and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30 months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.

Complications After Stent Placement for Aortic Coarctation: A Pictorial Essay of Computed Tomographic Angiography

Stent placement is commonly used to treat aortic coarctation. Although invasive angiography remains the gold standard, follow-up is often performed using computed tomography, which allows rapid, noninvasive assessment of the aorta and surrounding tissues. The goal of this pictorial essay is to provide a guide to the interpretation of these examinations. Normal and abnormal computed tomographic appearance of different stent types is shown along with reconstructions that can help assess stent integrity and the stent position in relation to the aortic wall and branches. Furthermore, imaging findings of complications including aortic wall injuries, restenosis, and intimal hyperplasia are depicted.

Aortic rupture during stenting for recurrent aortic coarctation in an adult: live-saving, emergency, NuDEL all-in-one covered stent implantation

We report a case of successful, life-saving implantation of a covered Cheatham Platinum stent, an all-in-one NuDEL catheter system, in an adult with aortic rupture after bare-metal stenting for re-coarctation of the aorta.

The "Dog Bone Technique" A Novel Easy and Safe Catheter Maneuver for Aortic Arch and Coarctation Stenting

BACKGROUND

Various techniques are described to facilitate stable stent implantation in aortic arch stenosis or coarctation. We describe an alternative technique, which due to its unique appearance during stent implantation, we have named "Dog Bone Technique" (DBT).

TECHNIQUE

The stent/balloon assembly is placed across the stenosis, the long sheath is retrieved to uncover the distal 20-50% of the stent. The balloon is inflated with the pressure inflator just to expand slightly the stent. Thereafter the sheath is pulled back and the proximal end is uncovered and partially inflated; therewith the assembly takes the typical "dog bone" shape before complete inflation and final positioning. Repositioning of the stent and control angiography is possible at each time of this procedure.

RESULTS

Between 1/2010 and 12/2014 we implanted 91 stents in 87 patients (mean age 20.2 years). About 71 patients had native or re-coarctation and 16 patients had transverse aortic arch stenosis. In 38 patients (44%) a pharmacological exercise test with Orciprenaline was performed during implantation resulting in high-cardiac output. In none of the patients reduction of cardiac output by adenosine or a rapid pacing of the right ventricle was required for stable stent implantation. All stents were implanted in the targeted position using this single balloon technique. There were no acute or short-term complications detected.

CONCLUSION

DBT is a safe and feasible technique for aortic stent implantation even at high-cardiac output. Other additional techniques for stent placement are not necessary to obtain a stable final position in the target region.

Fabrication of Small Caliber Stent-grafts Using Electrospinning and Balloon Expandable Bare Metal Stents

Stent-grafts are widely used for the treatment of various conditions such as aortic lesions, aneurysms, emboli due to coronary intervention procedures and perforations in vasculature. Such stent-grafts are manufactured by covering a stent with a polymer membrane. An ideal stent-graft should have a biocompatible stent covered by a porous, thromboresistant, and biocompatible polymer membrane which mimics the extracellular matrix thereby promoting injury site healing. The goal of this protocol is to manufacture a small caliber stent-graft by encapsulating a balloon expandable stent within two layers of electrospun polyurethane nanofibers. Electrospinning of polyurethane has been shown to assist in healing by mimicking native extracellular matrix, thereby promoting endothelialization. Electrospinning polyurethane nanofibers on a slowly rotating mandrel enabled us to precisely control the thickness of the nanofibrous membrane, which is essential to achieve a small caliber balloon expandable stent-graft. Mechanical validation by crimping and expansion of the stent-graft has shown that the nanofibrous polyurethane membrane is sufficiently flexible to crimp and expand while staying patent without showing any signs of tearing or delamination. Furthermore, stent-grafts fabricated using the methods described here are capable of being implanted using a coronary intervention procedure using standard size guide catheters.

Most Coarctations, Recoarctations, and Coarctation-Related Aneurysms Should Be Treated Endovascularly

For patients with coarctation of the aorta (CoA), surgical intervention results in an overall survival rate nearly twice that of medical management. Therefore, surgical correction of CoA has traditionally been warranted in the majority of patients, even though open repair entails its own complications. With the advent of endovascular technology, many interventionalists hoped that this approach would decrease the complications associated with open surgical repair of CoA. Nevertheless, there is still an ongoing debate about the merits of traditional open surgery versus endovascular therapy. In this review, we discuss the role of these two approaches for the management of CoA, recoarctation, and coarctation-related aneurysms.

Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II)

OBJECTIVES

This study aimed to describe the safety and short-term efficacy of the Covered Cheatham-Platinum stent (CCPS) in treating or preventing aortic wall injury (AWI) in patients with coarctation of the aorta (CoA).

BACKGROUND

The COAST II trial (Covered Cheatham-Platinum Stents for Prevention or Treatment of Aortic Wall Injury Associated with Coarctation of the Aorta Trial) is a multicenter, single-arm trial using the CCPS for the treatment and/or prevention of AWI in patients with CoA and pre-existing AWI or increased risk of AWI.

METHODS

Patients were enrolled if they had a history of CoA with pre-existing AWI (Treatment group) or with increased risk of AWI (Prevention group). Pre/post-implant hemodynamics and angiography were reported. A core laboratory performed standardized review of all angiograms. One-month follow-up was reported.

RESULTS

A total of 158 patients (male = 65%; median age 19 years) underwent placement of CCPS. Eighty-three patients had pre-existing AWI. The average ascending-to-descending aorta systolic gradient improved from 27 ± 20 mm Hg to 4 ± 6 mm Hg. Complete coverage of pre-existing AWI was achieved in 66 of 71 patients (93%) with AWI who received a single CCPS. Ultimately, complete coverage of AWI was achieved in 76 of 83 patients (92%); 7 patients had minor endoleaks that did not require repeat intervention. Four patients experienced important access site vascular injury. There were no acute AWI, repeat interventions, or deaths.

CONCLUSIONS

The CCPS can effectively treat and potentially prevent AWI associated with CoA. Access site arterial injury is the most common important complication. Longer-term follow-up is necessary to define mid- and late-term outcomes.

Circumferential stent fracture repaired using a covered stent in a 42-year-old man with coarctation of the aorta

We present a case of circumferential fracture of aortic coarctation stent with severe re-stentosis presenting 16 years after initial stent implantation with end-stage renal disease. The patient was treated with a covered stent using the stent-in-stent technique. The use of an ultra-high-pressure balloon was proved necessary to overcome the tight, non-compliant stenosis.

Stent dilatation of atretic aortic coarctation in an adult-case report and literature review

Background

Patients with functional aortic interruption of the descending thoracic aorta at the isthmus due to severe coarctation in association with atretic lumen are extremely rare in the adult population. The management is challenging and carries high morbidity and mortality.

Case presentation

We describe successful percutaneous reconstruction using a covered stent in a similar patient who is doing well two-years after intervention. A literature search was done to explore management strategies and their long-term outcomes for better understanding.

Conclusions

This report is an attempt to highlight the role of minimal invasive approach in the management of rare, severe coarctation of the aorta in adult patients to avoid morbidity and mortality associated with more invasive procedures.

Coarctation of the aorta: Management from infancy to adulthood

Coarctation of the aorta is a relatively common form of congenital heart disease, with an estimated incidence of approximately 3 cases per 10000 births. Coarctation is a heterogeneous lesion which may present across all age ranges, with varying clinical symptoms, in isolation, or in association with other cardiac defects. The first surgical repair of aortic coarctation was described in 1944, and since that time, several other surgical techniques have been developed and modified. Additionally, transcatheter balloon angioplasty and endovascular stent placement offer less invasive approaches for the treatment of coarctation of the aorta for some patients. While overall morbidity and mortality rates are low for patients undergoing intervention for coarctation, both surgical and transcatheter interventions are not free from adverse outcomes. Therefore, patients must be followed closely over their lifetime for complications such as recoarctation, aortic aneurysm, persistent hypertension, and changes in any associated cardiac defects. Considerable effort has been expended investigating the utility and outcomes of various treatment approaches for aortic coarctation, which are heavily influenced by a patient’s anatomy, size, age, and clinical course. Here we review indications for intervention, describe and compare surgical and transcatheter techniques for management of coarctation, and explore the associated outcomes in both children and adults.

Intravascular stent therapy for coarctation of the aorta

Intravascular stent therapy is considered a primary therapeutic option for most adults and adolescents with coarctation of the aorta. This review highlights the indications, technical considerations, procedural aspects, and limited long-term outcome data when using this intervention. Stent technology has continued to evolve with potential for further modifications since its inception in the early 1990s. The best therapeutic approach, e.g., stenting versus surgery, in the treatment of native coarctation continues to be debated due to the paucity of long-term clinical and imaging data in both groups.

Recurrent coarctation: interventional techniques and results

Coarctation of the aorta (CoA) accounts for 5% to 8% of all congenital heart defects. With all forms of interventions for native CoA, repeat intervention may be required due to restenosis and/or aneurysm formation. Restenosis rates vary from 5% to 24% and are higher in infants and children and in those with arch hypoplasia. Although repeat surgery can be done for recurrent CoA, guidelines from a number of professional societies have recommended balloon angioplasty with or without stenting as the preferred intervention for patients with isolated recoarctation. For infants and young children with recurrent coarctation, balloon angioplasty has been shown to be safe and effective with low incidence of complications. However, the rates of restenosis and reinterventions are high with balloon angioplasty alone. Endovascular stent placement is indicated, either electively in adults or as a bailout procedure in those who develop a complication such as dissection or intimal tear after balloon angioplasty. Conventionally bare metal stents are used; these can be dilated later if required. Covered stents, introduced more recently, are best reserved for those who have aneurysm at the site of previous repair or who develop a complication such as aortic wall perforation or tear. Stents produce complete abolition of gradients across the coarct segment in a majority of cases with good opening of the lumen on angiography. The long-term results are better than that of balloon angioplasty alone, with very low rates of restenosis. However, endovascular stenting is a technically demanding procedure and can be associated with serious complications rarely.

Atretic aortic coarctation in a 32-year-old woman diagnosed after her third pregnancy, treated percutaneously using a covered stent

Atretic aortic coarctation is a severe form of coarctation of aorta, where there is loss of luminal communication at the site of aortic isthmus. We present a case of a 32-year-old woman who had long-standing, treatment-resistant hypertension. She had three pregnancies. The third pregnancy ended in premature labor of a newborn female infant who was found to have severe coarctation of aorta. This diagnosis in the newborn child prompted proper evaluation of the mother, who was found to have atretic coarctation. The woman was treated successfully using a covered Advanta V12 stent (Atrium, Hudson, NH, USA), after percutaneous needle puncture of the atretic isthmus. Anatomical orientation of the aorta at the site of coarctation and its relationship to the safety of needle puncture approach are discussed. This case brings an old lesson to the table, where proper evaluation of severe, treatment-resistant hypertension in adults should include screening for secondary causes. <Learning objective: Evaluation of severe and resistant systemic hypertension in adults should include screening for aortic coarctation. Pregnancy in women with coarctation of aorta carries significant risk to both the woman and the fetus. Atretic coarctation is a severe form of coarctation where there is complete obstruction of aortic isthmus. This can be treated successfully by percutaneous approach using covered stents.>.

Most Coarctations, Recoarctations, and Coarctation-Related Aneurysms Should Be Treated Endovascularly

For patients with coarctation of the aorta (CoA), surgical intervention results in an overall survival rate nearly twice that of medical management. Therefore, surgical correction of CoA has traditionally been warranted in the majority of patients, even though open repair entails its own complications. With the advent of endovascular technology, many interventionalists hoped that this approach would decrease the complications associated with open surgical repair of CoA. Nevertheless, there is still an ongoing debate about the merits of traditional open surgery versus endovascular therapy. In this review, we discuss the role of these two approaches for the management of CoA, recoarctation, and coarctation-related aneurysms.

Intermediate Outcomes in the Prospective, Multicenter Coarctation of the Aorta Stent Trial (COAST)

BACKGROUND

The Coarctation of the Aorta Stent Trial (COAST) was designed to assess the safety and efficacy of the Cheatham Platinum stent when used in children and adults with native or recurrent coarctation. Acute outcomes have been reported. We report here follow-up to 2 years.

METHODS AND RESULTS

A total of 105 patients underwent attempted implantation, with 104 successes. There were no procedural deaths, serious adverse events, or surgical intervention. All patients experienced immediate reduction in upper- to lower-extremity blood pressure difference with sustained improvement to 2 years. Rates of hypertension and medication use decreased from baseline to 12 months and remained largely unchanged at 2 years. Six aortic aneurysms have been identified: 5 were successfully treated with covered stent placement, and 1 resolved without intervention. Stent fractures were noted in 2 patients at 1 year and 11 patients at 2 years, with evidence of fracture progression. To date, only larger stent diameter was associated with stent fracture. Twelve additional fractures have occurred after 2 years. No fracture has resulted in loss of stent integrity, stent embolization, aortic wall injury, or reobstruction. Nine reinterventions occurred in the first 2 years for stent redilation and address of aneurysms, and 10 additional reinterventions occurred after 2 years.

CONCLUSIONS

The Cheatham Platinum stent is safe and associated with persistent relief of aortic obstruction. Stent fracture and progression of fracture occur but have not resulted in clinically important sequelae. Reintervention is common and related to early and late aortic wall injury and need for re-expansion of small-diameter stents.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00552812.

Partially uncovered Cheatham platinum-covered stent to treat complex aortic coarctation associated with aortic wall aneurysm

Percutaneous treatment of aortic coarctation is a widely used option. Covered stents have increased the profile of efficacy and safety of this procedure. Here we report on a 32-year-old woman with significant aortic recoarctation associated with aortic wall aneurysm and close proximity of both lesions to the origin of both the subclavian arteries. It was decided to manually and partially uncover the proximal part of the stent to have a hybrid stent that could act as a bare stent at the level of the origin of the subclavian arteries and as a covered stent at the level of the aneurysm.