Thanopoulos et al, in a recent report, presented their experience in the treatment of coarctation of the aorta (CoA) in children with stent implantation. They retrospectively analyzed 74 consecutive patients (42 with native and 32 with recurrent CoA) who had completed 6 years of follow-up and concluded that “early management of CoA with stent implantation is a safe alternative to surgical treatment.” We congratulate with the investigators especially for the data they report on medium-term follow-up.

Recent guidelines have been published for the transcatheter treatment of primary and recurrent CoA. Ballooning and/or stenting is indicated when there is a transcoarctation peak gradient of >20 mm Hg at the time of catheterization, although intervention may be warranted with less severe gradients if there is systemic hypertension with anatomic narrowing that may be contributing to the hypertension. Thanopoulos et al described 62 discrete CoA and 62 hypertensive patients (84%). What do you consider a discrete CoA? A CoA with a pressure gradient <20 mmHg? Was the hypertension in those patients severe?

Moreover, the Congenital Cardiovascular Interventional Study Consortium (CCISC) showed a technical success rate of 99% in a series of 588 procedures. Two patients developed aortic dissection and rupture, and the procedures were terminated and emergent surgery was undertaken. There was a total of 84 complications occurring in 69 patients (11.7%). The CCISC encountered 28 instances of stent migration (4.8%). The CCISC reported 8 angiographically evident intimal tears (1.3%). Neurologic events including cerebral vascular accidents occurred in 6 procedures (1%). Significant femoral vessel injuries were reported in 15 procedures (2.6%).

Conversely, Thanopoulos et al report only 2 procedural complications (traumatic aneurysm and femoral pseudoaneurysm). No late aortic aneurysm or recurrent coarctation was identified during the 6-year follow-up period, but 32 patients underwent repeat dilation. At the end of follow-up, 85% of patients were normotensive. Therefore, is the low rate of complications reported by the investigators due to correct patient selection or simply luck?

Currently, between the age of 1 year and the time when a child reaches a weight of 30 to 35 kg (usually 9 to 11 years of age), there are insufficient data to determine whether surgical or endovascular intervention is preferable for native lesions. Also awaited are long-term results that will ultimately decide if stent implantation should be extended to everyone with recurrent coarctation or only those who meet a high-risk criterion.