The aim of this study was to describe the clinical impact of management of coarctation of the aorta by transcatheter stent placement in the context of longer term management of systemic hypertension. In the long term, poor outlook associated with untreated coarctation of the aorta is likely to relate to uncontrolled systemic hypertension. Transcatheter stent placement to treat native and recurrent coarctation of the aorta is an established therapy in adolescents and adults. There remains confusion about longer term outcomes, particularly the relation between procedural success and improvement in blood pressure (BP) control. Improvement in lifelong systemic BP control after transcatheter stent placement remains unproved. Forty patients underwent transcatheter stent placement over a 10-year period (2001 to 2010) at the Yorkshire Heart Centre. The average age at the time of procedure was 25 years (range 14 to 57). There was a reduction in peak systolic gradient across the coarcted segment from 25 to <10 mm Hg in 35 of 39 patients. After stent placement, there was a significant improvement in systolic BP control at early and later follow-up (mean 155 mm Hg before the procedure and 134 mm Hg at 2.81-year follow-up, p <0.0001). There was 1 early procedural adverse event (stent embolization) and 1 late adverse event (lower limb claudication). In conclusion, transcatheter stent placement for the management of aortic coarctation is associated with a reduction in systolic BP that is maintained over the medium term. A significant minority of patients remain significantly hypertensive, and the best management strategy for this group of patients remains unclear.
Aortic isthmic coarctation is a complex disorder in which aortic obstruction is only one part of an arteriopathy with lifelong implications that persist after initial correction of the aortic obstruction. A key association of aortic coarctation is systemic hypertension, which in turn has a strong association with adverse vascular events, the risks relating to the degree of hypertension and its duration. The extent to which treatment of coarctation reduces ongoing hypertension is incompletely understood. Whether the overall history can be modified by an aggressive approach to arch obstruction is also uncertain, but there is an increasing reluctance to accept even small gradients in patients with hypertension with native or recurrent coarctation. Although surgical treatment has a long and proved track record, particularly in the treatment of infants and smaller children, transcatheter therapy has emerged as a highly effective strategy in older children and adults. We sought to determine the effect of transcatheter treatment on systemic blood pressure (BP) in the medium term in a group of adolescent and adult patients with native or recurrent coarctation.
Methods
Forty patients with native or recurrent coarctation of the aorta underwent transcatheter stent placement over a 10-year period (2001 to 2010) at the Yorkshire Heart Centre (Leeds, United Kingdom). Minimum preprocedural investigations included clinic BP, transthoracic echocardiography, electrocardiography, and cardiac magnetic resonance imaging or computed tomography. Postprocedural investigations included clinic BP at 3 months, 1 year, and 3 years; transthoracic echocardiography at each visit; and repeat cardiac magnetic resonance imaging, computed tomography, or diagnostic cardiac catheterization at 3 months and 1 year. BP was measured in the right arm before physician review by a nurse blinded to the diagnosis and preprocedural or postprocedural status.
Data on all patients who underwent transcatheter stent placement, including demographics, surgical notes, interventional procedural, and angiographic data, were retrospectively collected from patient records. Additional information was obtained from archived echocardiographic examinations, cardiac magnetic resonance imaging studies, and cardiac catheterization procedures. Procedural success was defined as a reduction in the pressure gradient across the coarctation site to <10 mm Hg with an improvement in the luminal diameter of the obstructed aorta to >90% of the adjacent aorta proximal to the obstruction.
The stent placement technique has been extensively reported and is only briefly described here. Procedures were performed under general anesthesia, having obtained written consent. Vascular access was obtained from the right femoral artery, and the access site was preclosed with a Perclose hemostasis suture (Abbott Vascular, Santa Clara, California) before upsizing to a final sheath size of 11Fr to 13Fr. Systemic heparin (100 U/kg) was given after access was obtained. Biplane fluoroscopy was used in all cases. Right ventricular pacing was occasionally used, particularly if there was significant aortic regurgitation. In some patients, especially those with severe coarctation or virtual acquired atresia, an approach from the left radial artery was used to cross the coarctation segment from above and establish a femoral-radial guidewire rail for stent deployment. Stent postdilatation was performed infrequently and when necessary to improve apposition of the stent to the aortic wall. Occasionally, staged dilatation of the deployed stent was performed in a repeat procedure. In several other patients, concomitant transverse arch hypoplasia or failure to adequately abolish arch obstruction necessitated a repeat procedure.
Results
Demographic and procedural data are listed in Table 1 for the 20 patients with native coarctation and in Table 2 for the 20 patients with recurrent coarctation (1 with angioplasty, 8 with subclavian flap repair, 6 with end-to-end anastomosis, and 5 with patch repair). Of 40 patients, 11 were female. The average age at the time of the procedure was 24.9 years (range 13.8 to 56.6 years). Peak systolic gradient under general anesthesia was reduced from a mean of 24.7 mm Hg (range 8 to 48) before stent placement to a mean of 3.4 mm Hg (range 0 to 22) after stent deployment (p <0.10 × 10 −11 ). There were 2 procedure-related complications. The first was stent embolization to the descending aorta and the second femoral artery stenosis with symptomatic claudication. One patient died 1 year after the procedure from a noncardiac cause. Five patients underwent further procedures during follow-up. In 1 patient, there was important residual coarctation requiring a second stent; in 3, the original stent required further dilatation; and in the fifth, there was moderate residual transverse arch hypoplasia that remains untreated. Four patients had residual gradients >10 mm Hg at the end of their first procedure, of whom 2 remain persistently hypertensive and 2 have undergone repeat procedures (1 required a further stent, and the other has persistent as yet untreated transverse arch hypoplasia; Figure 1 ). Thirty of 39 patients attended for postprocedural surveillance for aneurysm formation and other potential complications at 3 months, and 32 of 38 patients attended at 1 year. All showed no procedure-related complications at the site of stent placement.
| Age at Procedure (yrs) | Gender | Height (m) | Weight (kg) | Fluoroscopy Time (min) | Dose (cGy/cm 2 ) | Procedure Time From Sheath Placement to Removal (min) | Sheath (Fr) | Stent | Balloon 1 Size | Balloon 1 Type | Balloon/Aortic Ratio | Preprocedural Gradient (mm Hg) | Postprocedural Gradient (mm Hg) | Closure Device |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 34.9 | F | 1.8 | 87 | 6.5 | 7,870 | 40 | 12 | 34 CCP | 18 | BIB | 1 | 15 | 1 | 1 |
| 15.2 | M | 1.8 | 84.5 | 7.3 | 8,790 | 52 | 12 | 34 CCP | 18 | BIB | NA | 27 | 0 | 1 |
| 15.3 | M | 1.7 | 59.6 | 9.8 | 5,270 | 78 | 12 | 34 CCP | 16 | BIB | 1 | 28 | 13 | 1 |
| 26.3 | M | 1.7 | 64.1 | 12.2 | 10,840 | 154 | 12 | 45 CCP | 20 | BIB | NA | 20 | 0 | 1 |
| 28.7 | M | 1.7 | 88 | 10.4 | 5,612 | 49 | 11 | 34 CCP | 12 | BIB | NA | 15 | 0 | 0 |
| 23.8 | M | 1.8 | 75 | 9.2 | 6,180 | 97 | 13 | 39 CCP | 14 | BIB | 1 | 48 | 0 | 1 |
| 34.9 | M | 1.8 | 79.4 | 11 | 5,190 | NA | 12 | 34 CCP | 14 | BIB | 1.05 | 25 | 0 | 0 |
| 16.3 | M | 1.8 | 76.6 | 15.5 | 3,602 | 155 | 12 | 34 CCP | 14 | BIB | 1 | 41 | 0 | 1 |
| 29.2 | F | 1.6 | 77 | 9.5 | 7,188 | 66 | 12 | 34 CCP | 10 | BIB | 1 | 36 | 0 | 1 |
| 22.8 | M | 1.8 | 63.6 | 10.9 | 1,645 | 126 | 12 | 39 CCP | 16 | BIB | 1 | 46 | 1 | 1 |
| 56.6 | F | 1.5 | 106 | 12.1 | 11,079 | 100 | 13 | 45 CCP | 18 | BIB | 1 | 41 | 0 | 1 |
| 43.2 | M | 1.7 | 84 | 16.8 | 7,127 | 107 | 12 | 39 CCP | 16 | BIB | 1.06 | 29 | 0 | 1 |
| 35.4 | M | 1.7 | 114.8 | 7.4 | 5,343 | 79 | 13 | 39 CCP | 18 | BIB | 1.06 | 19 | 3 | 1 |
| 26.6 | M | 1.8 | 77 | 14.2 | 3,830 | 85 | 12 | 39 CCP | 14 | BIB | 0.97 | 31 | 3 | 1 |
| 15 | M | 1.7 | 59 | 9.5 | 3,489 | 182 | 13 | 39 CCP | 20 | BIB | 1.1 | 13 | 3 | 1 |
| 13.8 | M | 1.76 | 60.15 | 9.1 | 3,973 | 57 | 11 | 34 CCP | 14 | BIB | 1.14 | 20 | 2 | 1 |
| 17 | M | 1.8 | 97 | 11.6 | 9,283 | 71 | 13 | 39 CCP | 18 | BIB | 1.06 | 21 | 0 | 1 |
| 29.5 | M | 1.7 | 54 | 9.1 | 1,526 | 103 | 12 | 40 CP | 16 | BIB | 0.81 | 22 | 4 | 1 |
| 28.6 | M | NA | 80 | 96 | 20,447 | 390 | 18 | 39 CCP, Gore | 16 | BIB | NA | NA | NA | 0 |
| 19.7 | M | NA | 85 | 8.6 | 4,305 | 49 | 12 | 39 CCP | 16 | BIB | 1.08 | NA | 0 | 1 |
| Age at Procedure (yrs) | Gender | Initial Procedure | Height (m) | Weight (kg) | Fluoroscopy Time (min) | Dose (cGy/cm 2 ) | Procedure Time From Sheath Placement to Removal (min) | Sheath (Fr) | Stent | Balloon 1 Size | Balloon 1 Type | Balloon/Aortic Ratio | Preprocedural Gradient (mm Hg) | Postprocedural Gradient (mm Hg) | Comments |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 39 | F | Angioplasty | 1.4 | 75 | 7 | 2,820 | 87 | 11 | J&J 308 | 15 | Crystal | NA | 35 | 5 | |
| 17.2 | F | SCF | 1.6 | 62.3 | 25.6 | 2,068 | 90 | 11 | J&J 308 | 15 | Crystal | 0.93 | 18 | 8 | |
| 22 | M | E-E | 1.7 | 70 | 21 | 7,730 | 93 | 12 | J&J 308 | 16 | BIB | 0.94 | 16 | 12 | |
| 17.9 | F | SCF | 1.7 | 47.2 | 13.7 | 2,990 | 71 | 12 | 34 CP | 16 | BIB | NA | 18 | 8 | |
| 14.5 | M | SCF | 1.8 | 53.3 | 8.5 | 2,140 | 80 | 12 | 34 CCP | 16 | BIB | NA | 24 | 0 | |
| 18.9 | M | Patch angioplasty | 1.9 | 77 | 6 | 4,160 | 57 | 12 | 35 CCP | 16 | BIB | 1 | 20 | 0 | |
| 18.2 | M | Patch angioplasty | 1.8 | 67 | 7.8 | 2,881 | 77 | 12 | 34 CCP | 16 | BIB | 1.13 | 20 | 0 | |
| 56 | F | E-E | 1.5 | 47.6 | 11.4 | 4,809 | 76 | 12 | 34 CP | 12 | BIB | 1.08 | 16 | 6 | |
| 17.7 | F | SCF | 1.6 | 56 | 13.8 | 5,342 | 96 | 13 | 34 CCP | 14 | BIB | 1.05 | 20 | 0 | |
| 15.8 | M | SCF | 1.7 | 65 | 7.3 | 3,239 | 110 | 12 | 34 CCP | 16 | BIB | 1 | 14 | 1 | |
| 14.1 | M | Patch angioplasty | 1.7 | 60 | 16 | 2,271 | 103 | 13 | 45 CCP | 14 | BIB | 0.96 | 29 | 18 | |
| 14.9 | M | E-E | 1.8 | 61 | 15.8 | 2,305 | 79 | 12 | 34 CCP | 14 | BIB | 0.82 | 25 | 22 | Transverse arch hypoplasia |
| 17.6 | F | Patch angioplasty | 1.8 | 65.9 | 12.3 | 3,945 | 72 | 12 | 26 LDMax | 14 | BIB | 1.29 | 45 | 5 | Transverse arch hypoplasia |
| 17.1 | F | E-E | 1.6 | 48.8 | 9.1 | 3,285 | 89 | 10 | 28 CP | 12 | BIB | 1 | 42 | 8 | |
| 36.2 | M | E-E | 1.7 | 84.6 | 12.1 | 6,106 | 62 | 12 | 34 CCP | 16 | BIB | 0.78 | 13 | 0 | |
| 20.7 | M | Patch, SCF | 1.7 | 59.5 | 6.6 | 2,606 | 53 | 12 | 39 CCP | 18 | BIB | 0.93 | 32 | 0 | |
| 17.2 | M | E-E | 1.7 | 67.8 | 14.8 | 3,155 | 99 | 13 | 26 LDMax | 17 | Z-MED | 1 | 10 | 8 | Transverse arch hypoplasia |
| 24.9 | M | SCF | 1.6 | 44 | 20 | 3,574 | 125 | 10 | 34 CP | 14 | BIB | 0.94 | 18 | 0 | Claudication |
| 42.6 | F | Patch angioplasty | 1.7 | 96 | 7.4 | 7,947 | 50 | 14 | 45 CCP | 18 | BIB | 0.89 | 8 | 2 | |
| 22.2 | M | SCF | 1.8 | 85.3 | 11.3 | 3,350 | 79 | 13 | 45 CCP | 18 | BIB | 0.94 | 19 | 0 |
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