Summary
Background
Endovascular stenting is a recognised treatment strategy for aortic coarctation (CoA) in adults. We assessed systemic hypertension control and the need for antihypertensive therapy after CoA stenting in adults.
Methods
Data were collected prospectively on 54 patients (36 men; mean age: 34 ± 16 years) who underwent endovascular stenting for CoA over a 7-year period. Five patients were excluded as they did not attend follow-up appointments. Patients underwent clinical examination, including right arm systolic blood pressure (SBP) and 24-hour ambulatory blood pressure monitoring at baseline, 6–12 weeks and 9–12 months.
Results
There was a significant fall in mean peak-to-peak systolic gradient (PG) across the CoA after stenting (26 ± 11 mmHg vs. 5 ± 4 mmHg; P < 0.01). There were successive reductions in right arm SBP and ambulatory SBP at baseline, 6–12 weeks and 9–12 months post-procedure (right arm: 155 ± 18 mmHg vs. 137 ± 17 mmHg vs. 142 ± 16 mmHg, respectively; all P -values <0.01; ambulatory: 142 ± 14 mmHg vs. 132 ± 16 mmHg vs. 131 ± 15 mmHg, respectively; all P -values <0.01). Twenty-four patients had severe CoA (PG >25 mmHg before stenting); baseline SBP was significantly higher in severe versus non-severe patients (160 mmHg vs. 148 mmHg; P = 0.02). The absolute reduction in PG after stenting was significantly higher in the severe group (31 ± 7 mmHg vs. 14 ± 5 mmHg; P < 0.0001), but there was no significant difference in SBP between groups at 6–12 weeks (141 mmHg vs. 135 mmHg; P = 0.21) or 9–12 months (139 mmHg vs. 139 mmHg; P = 0.96).
Conclusion
Endovascular stenting of CoA results in a significant reduction in SBP at 6–12 weeks, which is sustained at 9–12 months, with similar outcomes in severe and non-severe CoA groups.
Résumé
Justification
Le stenting endovasculaire est une stratégie thérapeutique validée de traitement de la coarctation aortique chez l’adulte. Nous avons évalué le contrôle de l’hypertension artérielle et la nécessité d’un traitement antihypertenseur chez des patients porteurs d’une coarctation aortique traités par stenting.
Méthode
Les données ont été collectées de façon prospective chez 54 patients, 36 hommes, âge moyen de 34 ± 16 ans, qui ont bénéficié d’un stenting endovasculaire pour coarctation aortique pendant une période de suivi de 7 ans. Cinq patients ont été exclus, car ils n’étaient pas suivis de façon régulière. Les patients ont été évalués cliniquement, avec mesures de la pression artérielle au bras droit ainsi qu’un enregistrement ambulatoire de la pression artérielle sur 24 heures, à l’état basal, à 6–12 semaines et à 9–12 mois.
Résultats
Nous avons observé une diminution significative du gradient intra-aortique pic à pic moyen après le stenting (26 ± 11 mmHg versus 5 ± 4 mmHg ; p < 0,01). Nous avons observé une réduction significative de la pression artérielle au bras droit et de la pression artérielle ambulatoire à l’état basal, à 6–12 semaines et à 9–12 mois au décours de la procédure (bras droit : 155 ± 18 mmHg versus 137 ± 17 mmHg versus 142 ± 16 mmHg respectivement ; valeurs de p < 0,01). Pour la pression artérielle ambulatoire, les chiffres sont respectivement de 142 ± 14 mmHg versus 132 ± 16 mmHg versus 131 ± 15 mmHg (valeurs de p < 0,01). Vingt-quatre patients ayant une coarctation aortique sévère avec un gradient intra-aortique > 25 mmHg avant le stenting ont bénéficié de façon très significative de cette procédure de stenting ; la pression artérielle à l’état basal était significativement plus élevée que chez les patients ayant un gradient en deçà de 25 mmHg (160 mmHg versus 148 mmHg ; p = 0,02). La réduction absolue du gradient de pression aortique au décours du stenting était significativement plus important dans le groupe ayant à l’état basal la coarctation la plus sévère (31 ± 7 mmHg versus 14 ± 5 mmHg ; p < 0,0001). Il n’y avait pas cependant de différence significative de pression artérielle systolique entre les groupes à 6–12 semaines (141 mmHg versus 135 mmHg ; p = 0,21) ou à 9–12 mois (139 mmHg versus 139 mmHg ; p = 0,96).
Conclusion
Le stenting endovasculaire de la coarctation aortique chez l’adulte conduit à une réduction significative du niveau de pression artérielle à 6–10 semaines, se maintient à 9–12 mois avec un suivi similaire qu’il s’agisse de patients ayant ou non une coarctation aortique sévère à l’état basal.
Background
Aortic coarctation (CoA) is a congenital narrowing of the upper descending thoracic aorta adjacent to the site of attachment of the ductus arteriosus (ligamentum arteriosum) . CoA represents 5–10% of all congenital cardiac lesions . CoA has a male predominance and has been associated with conditions that include gonadal dysgenesis (Turner’s syndrome), Shone’s complex, bicuspid aortic valve, intracranial aneurysms, patent ductus arteriosus, ventricular septal defect and mitral stenosis or regurgitation . If left untreated, CoA is associated with high morbidity and mortality . The first surgical repair for CoA was performed in 1945 . Various surgical techniques were developed across age groups, including resection with end-to-end anastomosis, extended end-to-end anastomosis, end-to-side anastomosis, extra-anatomical bypass, tube graft replacement, patch augmentation and subclavian flap aortoplasty . Surgical repair is performed depending on age of presentation, ranging from newborns to adults . Patients can develop restenosis of the previously repaired CoA with the passage of time, because of fibrous scar tissue or residual ductal tissue contracting.
In 1982 , the first percutaneous balloon dilatation was successfully performed in an infant and, since then, has also been successfully performed in recurrent CoA . While balloon dilatation showed promising results in the short-term, because of the elastic recoil properties of the aorta, restenosis was common, being reported in up to 20–30% of patients . In 1991, O’Laughlin et al. successfully used balloon-expandable endovascular stents, and this technique is currently an established management strategy in adults with CoA .
The main objectives of this study were to assess systemic hypertension outcomes and the need for antihypertensive therapy in adolescent and adult patients undergoing primary stenting for CoA.
Methods
Study population
The data were collected prospectively for 54 adolescent and adult patients who underwent transcatheter stenting of CoA over a 7-year period. These patients were followed up as part of a non-randomized observational protocol. Informed written consent was obtained from all patients before the stenting procedure, according to local guidelines. Patients were defined as being hypertensive if they had blood pressure readings (right upper limb) >140/90 mmHg on more than one occasion at rest . Blood pressure was measured at 6–12 weeks and 9–12 months at clinical follow-up, and included outpatient ambulatory blood pressure monitoring. Clinical blood pressure was measured 10 minutes after arrival of the patient at the outpatient department, in an upright position in the right upper limb with an automated cuff.
Stent deployment technique
A single lead operator performed all procedures with either covered or uncovered stents, according to operator preference and angiographic findings. All procedures were performed under general anaesthesia. The covered stents used were the Cheatham Platinum (CP) stent™ (NuMED, Hopkinton, NY, USA) and the Adventa V12™ stent (Atrium, Mijdrecht, Netherlands); the uncovered stents used were the Max™ LD stent (EV3, Plymouth, MN, USA), the PALMAZ™ stent (Cordis [Johnson & Johnson], Roden, the Netherlands), the CP Stent™ (NuMED, Hopkinton, NY, USA) and the JOSTENT™ (Abbott Vascular Devices, Santa Clara, CA, USA). The balloons used for deployment of non-premounted stents included the balloon-in-balloon (BIB™; NuMED, Hopkinton, NY, USA) and Cristal™ balloons (Balt, Montmorency, France).
Vascular access was achieved from the femoral artery in all patients. Further arterial access was achieved using the right radial artery in all patients except one, in whom brachial artery access was obtained. In two patients, the CoA site could not be crossed from the femoral approach, and the wire was snared from the femoral artery after antegrade crossing of the coarctation from an upper limb vessel. Femoral arterial access sites were preclosed using a Perclose A-T™ or Proglide™ device (Abbott Vascular Devices, Santa Clara, CA, USA) in 49 (91%) patients. Patients received 5000 IU heparin. Aortic pressures were simultaneously recorded in the ascending aorta and descending thoracic aorta to measure the peak-to-peak systolic gradient (PG) across the CoA segment. An aortic arch angiogram was taken in the left lateral and right anterior oblique views. Measurements were then obtained from the images, including the diameter of the aorta proximal and distal to the site of obstruction. The diameter of the balloon was chosen to equal that of the normal portion of the transverse arch or proximal isthmus at the level of the take off of the left subclavian artery.
The location of the CoA relative to landmarks within the chest was noted for reference during positioning and implantation. Implantation was performed using standard techniques. After successful deployment of the CoA stent, the femoral artery access site was closed with the Perclose A-T™ or Proglide™ preclosure device.
Major complications were defined as mortality or complications requiring surgical intervention – either cardiac or vascular – including the need for blood transfusions.
Statistical analysis
Analysis was performed using SPSS 17.0 (SPSS, Chicago, IL, USA). Group means were compared using paired or unpaired Student’s t tests as appropriate. Absolute PG reduction (baseline PG – post-stenting PG) and percentage PG reduction ([absolute PG reduction/baseline PG] × 100) were calculated for each procedure. The correlations between baseline PG and baseline systolic blood pressure (SBP), and between PG reduction (absolute and percentage change) and SBP reduction (baseline – post-stenting SBP) at 6–12 weeks and 9–12 months were assessed using Pearson’s correlation coefficients. Additionally, the predictive accuracy of absolute and percentage PG reduction to predict adequate SBP control (<140/90 mmHg) was determined using receiver-operating characteristic (ROC) analysis, and expressed as area under the curve (AUC). To determine statistical significance, various AUCs were compared with 0.5 and their 95% confidence intervals (CIs) calculated. Based on invasive haemodynamic data we divided patients into severe CoA (PG >25 mmHg) and non-severe CoA (PG ≤25 mmHg) groups for comparison. All statistical tests were two-tailed and a P -value <0.05 was considered significant. Stepwise univariate and multivariable logistic regression analyses were performed for the outcome of SBP <140 mmHg at 12 months using the following variables: age, sex, preprocedural SBP, preprocedural PG, post-procedural PG, absolute and percentage PG reduction. An alpha level of 0.05 was used for entry into multivariable analysis.
Stepwise logistic regression
On univariate logistic regression, only preprocedural SBP significantly predicted a 12-month outcome of SBP <140 mmHg ( P < 0.05). All the other variables tested failed to reach significance (all P -values >0.05). Multivariable analysis was therefore not performed.
Results
Study population
Over a 7-year period, a total of 54 consecutive patients underwent CoA stenting. Five patients were excluded, as they did not attend follow-up appointments within the specified time periods for blood pressure monitoring. Forty-nine patients had complete measurements; their mean age was 34 ± 16 years (range: 15–72 years). Patient demographics, lesion characteristics and associated conditions are given in Table 1 .
| Variable | |
|---|---|
| Men | 36 |
| Age (years) | 34 ± 16 |
| Native CoA | 35 |
| Previous surgical repair | 14 |
| Previous balloon dilatation | 10 |
| Stent strut fracture in previous CoA stent | 1 |
| Associated conditions | |
| Bicuspid aortic valve | 18 |
| Ventricular septal defect | 5 |
| Atrial fibrillation | 4 |
| Atrial septal defect | 3 |
| Turner’s syndrome | 3 |
| Patent ductus arteriosus | 3 |
| Wolff-Parkinson-White syndrome | 2 |
| Cerebral aneurysm | 1 |
| Dextrocardia | 1 |
| Parachute malformation of mitral valve | 1 |
| Dysplastic aorta | 1 |
| Waardenberg’s syndrome | 1 |
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