Author + information
- Basil Vasilios Thanopoulos, MD, PhD⁎ (, )
- Nicholaos Eleftherakis, MD,
- Konstadinos Tzanos, MD,
- Ioannis Skoularigis, MD and
- Fillipos Triposkiadis, MD
- ↵⁎Department of Pediatric Cardiology, Aghia Sophia Children's Hospital, Thivon and Levadias Street, Athens 115 27, Greece
To the Editor: There is limited information on the late results of stent implantation (SI) for adult coarctation of the aorta (CoA) (1–3). This study reports the initial and 5-year results in 46 patients who underwent SI for adult CoA.
Between April 1999 and November 2002, a total of 46 patients underwent SI for CoA. There were 26 women and 20 men, with a median age of 33 years (range 23 to 62 years) and median body weight of 63 kg (range 50 to 80 kg). Twenty-five and 21 patients had isolated native and recurrent CoA, respectively. Forty-three patients had discrete CoA and 3 patients had tubular stenosis, and 39 of the 46 patients (85%) were hypertensive (systolic blood pressure >140 mm Hg and/or diastolic pressure >90 mm Hg), receiving antihypertensive medications. The study excluded patients with hypoplasia of the distal aortic arch or aortic isthmus and those with complex CoA: complete near atresia and associated aneurysm. Hypoplasia was defined as a ratio of the diameter of aortic arch or isthmus to the diameter of the descending aorta at diaphragm of <0.6. Native CoA or re-coarctation was diagnosed if systemic hypertension and/or an arm-to-leg pressure gradient ≥20 mm Hg were present, and CoA was confirmed with magnetic resonance imaging (MRI).
All patients underwent cardiac catheterization and angiography under general anesthesia. An SI was performed in cases with a systolic pressure gradient ≥20 mm Hg and angiographic evidence of significant CoA (diameter of CoA ≤50% of that of descending aorta at the level of diaphragm).
The procedure of SI for CoA has been described previously in detail (1–4). In brief, Palmaz stents P4014 and P308 (Johnson & Johnson International Systems, Warren, New Jersey) dilatable to an adult aortic diameter were implanted. In 15 patients with severe stenosis and difficult CoA anatomy (long and anomalous CoA area, CoA close to the origin of left subclavian artery, large collateral circulation), the procedure was guided using the antegrade monitoring technique (4). Patients were discharged 1 to 2 days after the procedure and administered aspirin 3 to 5 mg/kg/day for 6 months. They were re-evaluated clinically at 1 and at 3 months after the procedure and then serially every 6 months. Follow-up included arm-to-leg pressure measurements, echocardiographic Doppler studies, chest radiography, and ambulatory 24-h blood pressure monitoring. All patients underwent a treadmill exercise test according to the Bruce protocol, and MRI evaluation including a brain 3-dimensional (3D) magnetic resonance angiography (MRA) at 1, 3, and 5 years after SI. In addition, all patients underwent multislice computed tomography (MSCT) at the end of the 5-year follow-up. A satisfactory late result was defined as the absence of restenosis (aortic diameter across the stents equal to the diameter of proximal isthmus) on MRI and MSCT, as well as a pressure gradient <20 mm Hg, measured by cuff sphygmomanometry.
Results are expressed as mean ± SD or mean with range as appropriate. Pre- and post-stent implantations comparisons were made using the paired Wilcoxon test. A value of p < 0.05 was considered significant.
Twenty-two patients had bicuspid aortic valves. Contrast-enhanced brain 3D MRA revealed the presence of aneurismal dilatations of the circle of Willis in 3 patients (23, 35, and 49 years old, respectively). Fifty stents were implanted in the 46 patients. Palmaz 4014 stents were placed in 36 patients, and Palmaz P308 stents were placed in 10 patients. The peak systolic pressure gradient across the CoA was reduced from 58 ± 17 mm Hg (range 26 to 93 mm Hg) to 6.5 ± 4.8 mm Hg (range 0 to 14 mm Hg) (p < 0.05). The diameter of the CoA increased from 5.2 ± 2.6 mm (range 2 to 6.5 mm) to 16.5 ± 2.8 mm (range 14 to 19 mm) (p < 0.05).
One proximal stent migration, treated percutaneously, and one femoral pseudoaneurysm requiring surgical correction were the only significant procedural complications. There were no early or late deaths, stent fracture, or any evidence of early or late aneurysm formation or any other complications throughout the follow-up period. Twenty patients (10 patients with bicuspid aortic valve and significant dilatation of the ascending aorta, 6 patients with severe stenosis and difficult CoA anatomy, and 4 over 60 years of age) underwent successful elective re-dilation (staged dilation) of the stents, 6 months to 3 years after the initial procedure, to a larger aortic diameter (up to 20 mm). The peak systolic pressure gradient was reduced from 28 ± 11 mm Hg (range 16 to 33 mm Hg) to 5.2 ± 2.8 mm Hg (range 0 to 5 mm Hg) after re-dilation. At the 5-year follow-up, no cases of re-coarctation were identified by angiography, MSCT, or MRI. Sphygmomanometric peak systolic blood pressure difference between arms and legs was 5.6 ± 4.3 mm Hg (range 0 to 10 mm Hg). The MSCT-measured diameter of the CoA site was 17.7 ± 3.2 mm (range 16 to 20 mm). No patient had absent or low volume distal pulses at follow-up, and there were no collaterals present on MSCT. Four patients with bicuspid aortic valve and dilation of the ascending aorta that progressed to aortic aneurysm underwent a successful modified Bental procedure 3 to 5 years after SI (Fig. 1). Seven female patients who became pregnant 1 to 3 years after SI had an uncomplicated labor and delivery. The aneurismal protrusions of the circle of Willis in the 3 of 46 patients were still present at brain 3D MRA at the 5-year follow-up (Fig. 2). At the 5-year follow-up, 31 (67%) of 46 patients were normotensive and receiving no medications (systolic and diastolic blood pressures 125 ± 12 mm Hg and 76 ± 10 mm Hg, respectively).
The findings of this study suggest that in adult patients with CoA, treatment with endovascular stents is a safe and effective alternative to surgical repair. Indeed, complete relief of CoA was achieved in all patients with no cases of re-coarctation and a very low complication rate during the procedure or at follow-up. However, it should be noted that these results were obtained in properly selected patients with favorable anatomy and staged dilation of the stents in patients with severe CoA, with bicuspid aortic valve, or older than 60 years of age.
Typical berry-like aneurysms of the circle of Willis were not found in our patient population. However, 3 of 46 patients had aneurismal protrusions of the circle of Willis. The clinical significance of these lesions is incompletely understood because of the lack of relevant clinical studies (1–3). However, it is our policy to treat them with chronic administration of beta-blockers as in Marfan syndrome and to recommend avoidance of strenuous activities.
Significant CoA during pregnancy may be associated with an increased risk for both mother and fetus. It should be noted that pregnancy was not associated with any maternal or fetal complication in all of our 7 women who became pregnant after stent implantation.
This study has several limitations. The most important is that it is not randomized. In addition, longer follow-up is necessary to asses the impact of longstanding hypertension and comorbidities such as bicuspid aortic valve and aneurysms of circle of Willis in the late outcome.
Please note: Presented at the 56th Annual Scientific Session of the American College of Cardiology, New Orleans, Louisiana, March 24–27, 2007.
- American College of Cardiology Foundation
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