Stenting of stenosed aortopulmonary collaterals: a new approach to palliation in pulmonary atresia with multifocal aortopulmonary blood supply

The role of stents in the treatment of congenital heart disease: Current status and future perspectives

Intravascular or intracardiac stenoses occur in many forms of congenital heart disease (CHD). Therefore, the implantation of stents has become an accepted interventional procedure for stenotic lesions in pediatric cardiology. Furthermore, stents are know to be used to exclude vessel aneurysm or to ensure patency of existing or newly created intracardiac communications. With the further refinement of the first generation of devices, a variety of "modern" stents with different design characteristics have evolved. Despite the tremendous technical improvement over the last 20 years, the "ideal stent" has not yet been developed. Therefore, the pediatric interventionalist has to decide which stent is suitable for each lesion. On this basis, currently available stents are discussed in regard to their advantages and disadvantages for common application in CHD. New concepts and designs developed to overcome some of the existing problems, like the failure of adaptation to somatic growth, are presented. Thus, in the future, biodegradable or growth stents might replace the currently used generation of stents. This might truly lead to widening indications for the use of stents in the treatment of CHD.

[Use of stents in pediatric cardiology. Initial results]

BACKGROUND AND AIM

Balloon-expandable stents are useful in treating vascular stenotic lesions associated with congenital heart defects. We report our experience of this device since 1997.

PATIENTS AND METHOD

Seventeen stents were implanted in 12 children in 13 procedures. The mean age of the patients was 82 months (range: 2-168 months). Eight patients had postsurgical stenoses in branch pulmonary arteries, three patients had aortic re-coarctation and one patient had a ductus-dependent complex heart defect. In the first eight patients we performed right catheterization, following the usual technique of percutaneous implantation with super-stiff wire and Mullins sheath. In the remaining patients, vascular access was through the femoral artery. The Palmaz stent was used in 13 patients, Express stents in three and Intrastent in one patient.

RESULTS

After stent implantation, the diameter of the narrowings increased from 3.1 mm (2.8-5.6) to 12 mm (10-15) (p < 0.002) and the gradient was reduced from 32 mmHg (21-45) to 8.5 mmHg (0-11.5) (p < 0.002). In the patient with ductus-dependent heart defect, the procedure allowed prostaglandin E1 withdrawal and hospital discharge. After a mean follow-up of 27 months (range: 1-60 months) one occurrence of late complete occlusion of branch pulmonary artery and one case of side-branch partial occlusion (right superior lobe branch) have been detected. One patient died from causes unrelated to the stent (prior cardiogenic shock). The remaining patients are asymptomatic and medication free.

CONCLUSION

The stent is a safe and effective device that could be used in a wide variety of stenotic vascular lesions.

Recommendations of the British Paediatric Cardiac Association for therapeutic cardiac catheterisation in congenital cardiac disease

The aims of these recommendations are to improve the outcome for patients after, and to provide acceptable standards of practice of therapeutic cardiac catheterisation performed to treat congenital cardiac disease. The scope of the recommendations includes all interventional procedures, recognising that for some congenital malformations, surgical treatment is equally as effective as, or occasionally preferable to, interventional treatment. The limitations of the recommendations are that, at present, no data are available which compare the results of interventional treatment with surgery, and certainly none which evaluate the numbers and types of procedures that need to be performed for the maintenance of skills. Thus, there is a recognised need to collect comprehensive data with which these recommendations could be reviewed in the future, and re-written as evidence-based guidelines. Such a review will have to take into account the methods of collection of data, their effectiveness, and the latest developments in technology. The present recommendations should, therefore, be considered as consensus statements, and as describing accepted practice, which could be used as a basis for ensuring and improving the quality of future care.

Stenting of stenosed aortopulmonary collaterals and shunts for palliation of pulmonary atresia/ventricular septal defect

Patients with unrepaired pulmonary artery atresia and ventricular septal defect (PA/VSD) depend on aortoplumonary collaterals and surgically created shunts for pulmonary blood flow. These vessels frequently develop stenoses with time, leading to hypoperfusion of lung segments and systemic hypoxemia. The purpose of this article is to describe catheter palliation of hypoxemic patients with PA/VSD who were not candidates for surgical repair. We present our experience with stent implantation for stenosis of aortopulmonary collaterals and shunts in these patients. Three patients with hypoplastic pulmonary arteries underwent stent placement in aortopulmonary collateral arteries (APCAs) or their shunts. Technical aspects of the interventional catheterization procedure are discussed in detail. Case 1 underwent placement of five stents in collateral vessels and one stent in the Blalock-Taussig shunt (BT) with dramatic increase in vessel size and improvement in saturations from 70% to 89%. Case 2 underwent placement of two overlapping stents in a collateral vessel with an increase in diameter of the collateral vessel from 2.3 to 6 mm and an improvement in saturation from 68% to 88%. Case 3 underwent placement of three overlapping stents in a BT shunt with an increase in diameter of the shunt from 2.2 to 6.6 mm and an improvement in saturation from 71% to 89%. All three patients had excellent clinical improvement and stable saturation at follow-up. Stent placement for maintaining patency of APCAs and aortopulmonary shunts is feasible and safe.

Use of self expanding stents in stenotic aortopulmonary shunts in adults with complex cyanotic heart disease

OBJECTIVE

To describe the use of self expanding stents in treating long segment stenosis of aortopulmonary shunts (APS) in adults.

DESIGN

Clinical records, catheterisation data, cineangiograms, and operation notes of four consecutive patients undergoing stent implantation since December 1994 were studied retrospectively.

SETTING

A tertiary referral centre for cardiac disease.

SUBJECTS

Four patients underwent cardiac catheterisation because of clinical deterioration. Their age ranged between 23 and 32 years. The underlying diagnosis was complex cyanotic heart disease in all. Three had a stenotic interposition graft, and one had a classic Blalock shunt.

RESULTS

There was one technical failure owing to migration of the stent distal to an ostial stenosis. The ability index, resting oxygen saturation, and exercise tolerance improved in the remainder. Their medium term results have been excellent.

CONCLUSIONS

This technique may further palliate adult patients with complex congenital heart disease, though the long term patency of stents is unknown.

Use of Palmaz stents to palliate pulmonary atresia with ventricular septal defect and stenotic aortopulmonary collaterals

A 29-year-old woman with pulmonary atresia and ventricular septal defect underwent palliative stenting of a stenotic aortopulmonary collateral. Follow-up demonstrated patent stents, with improved oxygenation and exercise capacity. This approach offers an attractive alternative to surgical shunt placement in select patients.

Endovascular stents in congenital heart disease

Acquired or de novo vascular obstructions can adversely affect the outcomes of management algorithms for children with congenital heart lesions. Although surgical repair is frequently feasible, some acquired or congenital obstructions are difficult to address in the operating theater. Presented is the recent experience with endovascular stents to relieve such stenoses, and their impact on patient care.

Balloon-expandable stenting in pediatric cardiology

Intravascular stent placement in Pediatric Cardiology has provided one of the most interesting and effective means of catheter treatment of congenital lesions. In the 5 years since it has been performed, balloon-expandable stent placement has provided relief of many previously untreatable vascular stenoses and has resulted in improvement of blood flow, reduction of right ventricular pressure and, in many cases, dramatic improvement of symptoms. In this article, the background of balloon-expandable stent placement is discussed, and specific observations are offered regarding the technique of implantation. The generally excellent results are presented and a number of novel problems and pitfalls are outlined. Finally, a brief summary of the wide ranging applicability of stent implantation is discussed, along with some of the important and imaginative new directions for the therapy.