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PubMed1995

Balloon angioplasty for native coarctation of the aorta.

Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed.

Adult↗
PubMed1968

Arterial wall metabolism in experimental hypertension of coarctation of the aorta of short duration.

Coarctation of the mid-thoracic aorata was surgically produced in mongrel dogs which were sacrificed from 4-12 wk after the operation. As compared to the findings in control animals, the sodium, chloride, and water content of the hypetensive portion of the coarcted thoracic aorta was significantly elevated, whereas the electrolyte and water content of the relatively normotensive portion of the coarcted aorta was normal. The sodium, potassium, and water content of the pulmonary artery, skeletal muscle, and cardiac muscle of the coarcted dog was not altered. These observations suggest that an elevated arterial pressure may influence the electrolyte and water composition of the arteries. The arterial pressure also may influence the content and synthesis of acid mucopolysaccharides (MPS) in the arteries since the content of sulfated MPS and the incorporation of injected radiosulfate into sulfated MPS were significantly increased in the hypertensive portion of the coarcted thoracic aorta but were significantly reduced in the relatively normotensive ("hypotensive") portion of the coarcted aorta. The observed increase in MPS may have been a factor directly responsible for the increase in the sodium content of the hypertensive aorta since MPS can act as polyelectrolytes and bind cations. Although the arterial pressure may influence certain metabolic functions in the arteries, it did not appear to have a direct effect on the arterial lipids since the lipid content of the hypertensive and of the relatively normotensive portions of the coarcted aorta were comparable to the values found in the normal aorta.

Animals↗
PubMed2007

Coarctation of the aorta: stenting in children and adults.

Coarctation of the aorta may present in infants, children, or adults, and it requires treatment to prevent serious morbidity and mortality. Recent advances in equipment and a growing collective experience have made placement of balloon-expandable stents a safe and effective alternative to surgery or angioplasty in a growing range of patients. This review seeks to provide a working aid for stenting of coarctation of the aorta, based on the techniques and technical considerations in practice at our institution. Between 1989 and 2005, the Congenital Cardiovascular Interventional Study Consortium (CCISC), a consortium of 17 centers, of which our institution is the largest contributor, performed 588 stent placements for coarctation of the aorta. Of the 588 procedures, 580 (98.6%) were successful, as defined by reduction of the gradient to less than 20 mm Hg or increase of the ratio of the diameter of the coarctation area (CoA) to the diameter of the descending aorta (DAo) to at least 0.8. There were a total of 84 complications occurring in 69/588 (11.7%) cases. The most common significant complications were femoral access vessel related 15/588 (2.6%), aneurysm formation 13/588 (2.2%), aortic dissection 9/588 (1.5%), and cerebrovascular accident 6/588 (1.0%). There were two procedure-related deaths (0.3%) recorded in the 16-year period. Many of these significant complications occurred in the same patients. Balloon-expandable stents should be considered a safe and very effective treatment modality in a significant subset of patients with coarctation of the aorta.

Adult↗
PubMedDate not supplied

Coarctation of the aorta in adults. Clinical presentation and results of surgery.

We studied the mode of presentation and results of surgery in 45 adults with coarctation of the aorta. Coarctation was unsuspected in 23 patients, 3 of whom presented with acute aortic dissection and 4 with severe aortic valve disease. Twenty seven were hypertensive before surgery. Three patients required emergency operation and all died. There was one death and one postoperative paraplegia amongst 39 patients who underwent elective operation. Of 21 preoperatively hypertensive patients studied at least 2 years after surgery blood pressure returned to normal levels in 10. Acute aortic dissection, aortic aneurysm formation and aortic valve disease complicate the surgical treatment of adult coarctation and hypertension may persist in as many as 50% of patients. Nevertheless surgery is preferable to the poor reported results of long term medical management.

Adolescent↗
PubMed1984

Coarctation of the aorta in infants.

Repair of coarctation of the aorta in the first year of life by resection and end-to-end anastomosis has been reported to have a high rate of recurrence, and recent studies favor angioplasty techniques. Forty-seven consecutive infants less than 1 year of age who were operated upon over a 20 year period were analyzed. The hospital mortality was analyzed in three groups: Group I--two of 11 patients (18%) with coarctation; Group II--one of nine patients (11%) with coarctation and ventricular septal defect; Group III--12 of 27 patients (44%) with coarctation and major intracardiac anomalies. There was no difference in age or body surface area between survivors and nonsurvivors. Repair was performed by a resection and end-to-end anastomosis to the distal aortic arch in 43 and by patch angioplasty in four. Anastomosis was performed with 5-0 silk suture prior to 1972. Since then, 7-0 polypropylene suture has generally been used. Arm/leg pressure gradient was assessed at rest by the Doppler technique in 31 long-term survivors of the end-to-end anastomosis technique; 24 of them had polypropylene suture used and seven had silk suture. Recurrence of coarctation was defined as arm/leg gradient greater than or equal to 20 mm Hg. Actuarial freedom from recurrence at 5 and 10 years was 91% in the polypropylene group versus 57% and 44% in the silk group. Good long-term results with low incidence of recurrent coarctation achieved by end-to-end anastomosis with fine polypropylene suture justify continued use of this technique in preference to angioplasty techniques, which sacrifice the left subclavian artery or introduce prosthetic materials. Techniques chosen for coarctation repair should be compared with current operative techniques and not older studies.

Age Factors↗
PubMed2003

New "right side median" approach for postoperative re-coarctation of the aorta.

Anatomic repair of postoperative recurrent coarctation of the aorta is surgically difficult using the conventional lateral approach. Therefore, we have developed a new approach to the stenotic aorta through a median sternotomy, involving division of the superior vena cava and left caudal displacement of the heart. This approach facilitates extensive dissection and mobilization of the descending aorta in the posterior mediastinum behind the heart and also facilitates direct anastomosis of the aortic arch and the descending aorta after resection of the stenosis. This approach is useful for anatomic repair of postoperative recurrent coarctation of the aorta and other posterior mediastinal procedures.

Adolescent↗
PubMed1995

Surgical repair of coarctation of the aorta in neonates: factors affecting early mortality and re-coarctation.

Between October 1979 and January 1993, 85 Chinese neonates in Hong Kong underwent surgical repair for coarctation of the aorta. Their mean (s.e.) age and body weight at operation was 15.6(8.5) days and 3.06(0.56) kg, respectively. Simple coarctation was present in 17 babies, while 36 had additional ventricular septal defect and 31 had associated major complex intracardiac lesions. Subclavian flap aortoplasty was performed in 56 babies, resection with end-to-end anastomosis in 18 and aortoplasty with the use of a GORETEX patch in 11. The overall early mortality rate was 16.5%. To identify risk factors for early operative mortality, various clinical variables, surgical options, associated heart lesions and dimensions of the aortic arch at different sites for each patient were reviewed. Univariate analysis identified statistically significant differences between the survivors and non-survivors for the following factors: preoperative body-weight, arterial pH and base excess, serum urea and creatinine levels. Stepwise logistic regression further distinguished serum creatinine levels and the period of operation as two significant risk factors. Contrary to previous reports, the dimensions of the aortic arch and type of surgery did not affect early operative mortality. Among the 71 hospital survivors followed for 38.2(38) months, residual or recurrent coarctation of the aorta was detected in 12(17%). The different surgical operations were not related to the incidence of late complication. The size of the distal transverse arch, however, was different (P=0.05) in those who did and did not develop aortic sequela. Successful balloon angioplasty was subsequently performed in 11 patients. In an era of echocardiography with prenatal diagnosis and therapeutic catheterization, early recognition of the disease with prompt prostaglandin infusion should prevent collapse of the baby, thus avoiding renal impairment and sever metabolic acidosis. Balloon angioplasty would offer a simple effective treatment of patients who developed aortic re-coarctation.

Aortic Coarctation↗
PubMed2002

Intermediate term follow-up of the end-to-side aortic anastomosis for coarctation of the aorta.

BACKGROUND: Classic techniques for repairing coarctation of the aorta, especially in neonates, have a significant incidence of recurrent obstruction. By connecting the descending aorta to the proximal aortic arch, the end-to-side aortic anastomosis isolates hypoplastic distal arch and encroaching ductal tissue from the anastomotic site. METHODS: Follow-up data were available for 88 patients (54 male) who underwent an end-to-side aortic anastomosis from November 1992 until November 1999. The median postoperative follow-up was 1.9 years (range, 0.1 to 6.3 years). Fifty-four patients were corrected as neonates. Thirty-four patients were operated on out of the neonatal period (> 1 month of age). A systolic blood pressure gradient > or = 20 mm Hg and a Doppler flow velocity > or = 2.5 ms across the area of repair were considered a recurrent obstruction. RESULTS: No patients in the pediatric group had a recurrent obstruction. In the neonatal group, 3 patients (5.5%) had recurrent obstruction. Of those, 2 patients had a reintervention performed; one reintervention was a balloon angioplasty and the other one was a reoperation. Kaplan-Meier analysis of the neonatal group revealed a 95.8% freedom from reintervention at 1 and 2 years. CONCLUSIONS: The end-to-side aortic anastomosis is an effective repair for coarctation of the aorta. Even when performed in the neonatal period, recurrence of coarctation is rare.

Anastomosis, Surgical↗
PubMed1997

[Coarctation of the aorta and its surgical treatment].

Coarctation or isthmic stenosis of the aorta is defined as an abnormal obstruction situated at the junction of the aortic arch and the descending aorta near the site of ligamentus arteriosus. It is a common malformation representing 5 to 7.5% of all congenital heart diseases. Coarctation of the aorta is 2 to 3 times commoner in boys than in girls. Two clinical forms may be distinguished: asymptomatic isolated coarctation of childhood, the surgical treatment of which was first performed by Crafoord in 1944, and coarctation of the neonate and infant associated in over 2/3 of cases with other cardiovascular malformations, especially tubular hypoplasia of the aortic arch. The surgical correction of isolated coarctation is best performed between 6 months and 1 year of age in other to limit the incidence of residual hypertension. A modified Crafoord technique decreases the risk of restenosis and enables treatment of associated hypoplasia of the aortic arch in the same surgical procedure.

Adult↗
PubMed1979

Aortoplasty compared with resection for coarctation of the aorta in young children.

We repaired coarctation of the aorta in a group of 18 children less than 3 years old, using either resection with end-to-end anastomosis (8 patients, Group 1) or patch graft aortoplasty (10 patients, Group 2). The two groups were similar preoperatively in age, pressure difference between proximal and distal aorta (delta PA0), and severity of aortic arch hypoplasia. Three patients, all less than 2 months old, died early postoperatively. Among the survivors, the right brachial artery systolic pressure was significantly higher in Group 1 (133.1 +/- 7.0 mm Hg) (mean +/- standard error of the mean) than in Group 2 (102.5 +/- 7.2 mm Hg) (p less than 0.05). The delta PA0 was significantly higher in Group 1 (33.0 +/- 7.5 mm Hg) than in Group 2 (5.1 +/- 2.3 mm Hg) (p less than 0.01). Three patients in Group 1 required reoperation and were treated with patch graft aortoplasty; relief of delta PO0 was complete in 2. Patch graft aortoplasty is more effective than resection in reducing proximal aortic systolic pressure and in relieving delta PA0 in infants and small children with coarctation of the aorta.

Aorta, Thoracic↗
PubMed1975

Simplified operative technique for the long-segment atypical coarctation of the aorta.

Simplified operative technique for the long-segment atypical coarctation of the aorta was described. The main objective of this technique is to gain quick access to both thoracic and abdominal aorta with minimal blood loss, and preservation of diaphragmatic function. This procedure consists of standard thoracotomy and pararectal incision with an entry into the retroperitoneal space. Long prosthetic graft was anastomosed in an end-to-side fashion to bypass the coarctated aorta. The graft is placed through peripheral circumference of the left hemidiaphragm, where phrenic nerve injury is not likely to occur. This technique was successfully applied to two cases of long-segment atypical coarctation of the aorta due to Takayasu's aortitis. Retroperitoneal placement of the graft prevents fatal hemorrhage due to direct contact with the graft. Contamination with transintestinal exudate can also be avoided. Results of the ten-year follow-up of the similar procedure in the literature is encouraging.

Adult↗
PubMed1990

Primary balloon dilatation of coarctation of the aorta in neonates.

Primary balloon dilatation of coarctation of the aorta was attempted in 10 consecutive neonates (age range 2-23 days). The coarctation site was crossed and the balloon inflated in all but one patient. In two patients with associated severe isthmal hypoplasia there was no change in the gradient after dilatation. In the remainder, the residual gradients were trivial and angiography showed complete relief of coarctation. Severe recoarctation developed 5-12 weeks after dilatation in five patients, each considered to have had an excellent initial result. The coarctation was rapidly progressive in three patients in whom Doppler studies within two weeks of the development of recoarctation had shown no significant gradient. In the other two patients progressive restenosis was charted by Doppler examinations over the course of 6-8 weeks. Three patients had a second, initially successful, dilatation procedure. One patient remained well with no residual gradient 18 weeks later. Stenosis recurred within eight weeks in the other two, and both have undergone successful surgical repair. Balloon dilatation of a native coarctation of the aorta gave excellent immediate results in most neonates. Severe isthmal hypoplasia is, however, a contraindication to balloon dilatation and early restenosis is an important problem. These results do not support the continued use of primary balloon dilatation of coarctation of the aorta in neonates.

Aorta, Thoracic↗
PubMed1997

Two-stage repair of adult coarctation of the aorta with congenital valvular lesions.

BACKGROUND: Coarctation of the aorta associated with intracardiac pathologic conditions presenting in adult life poses some technical and management challenges. When deciding on the best surgical strategy, the surgeon must pay careful attention to the changes that will occur in the circulation. METHODS: In our small series of 3 patients, the intracardiac pathologic lesions were corrected first, and the coarctation was repaired as a second-stage procedure 2 to 3 months later. RESULTS: All patients had an uneventful recovery from both operations. The potential problems of renal impairment caused by inadequate perfusion during bypass and perioperative systemic hypertensive complications resulting from coarctation of the aorta were not observed. At the time of coarctation repair as a second-stage procedure, anticoagulation was easily controlled. All 3 patients had short intensive care unit and hospital stays. CONCLUSIONS: Staged surgical repair of this complex pathologic combination in adult patients is a safe option and is easy to manage perioperatively.

Adult↗
PubMed1984

Bicuspid aortic valve morphology when associated with coarctation of the aorta.

Thirteen children and young adults with coarctation of the aorta as their principal cardiovascular abnormality, 11 with bicuspid aortic valves, were evaluated by orifice-view aortography to evaluate their aortic valvular morphology. For comparison 30 individuals with aortic valvular deformities but without coarctation of the aorta were similarly studied. Two distinct forms of bicuspid valves could be identified characterized by either the appearance of gross inequality of size of the two valve leaflets or an appearance wherein each leaflet closely approximated the size of the other, thus equally bicuspid. Excepting two individuals with normal, tricuspid, aortic valves, all of the patients with coarctation of the aorta had equally bicuspid aortic valves which contrasted to the group without coarctation in which the unequally bicuspid type predominated. This difference in bicuspid aortic valve morphology associated with coarctation of the aorta suggests a different developmental process involving the aortic valve as opposed to the situation in individuals without coarctation.

Adolescent↗
PubMed1999

Takayasu's arteritis and fibromuscular dysplasia as causes of acquired atypical coarctation of the aorta: retrospective analysis of seven cases.

Coarctation of the aorta usually occurs in the aortic isthmus: however, 2% of all coarctation is localized at atypical sites such as the aortic arch and the thoracic and/or abdominal aorta. Causal therapy involves vascular surgery, and during the procedure, biopsies of the involved vessels should be taken to establish the etiology. This study involved the retrospective analysis of clinical and histopathological findings for seven patients who underwent vascular surgical procedures (age range, 10-37 years; male/female ratio 3:4). Histopathological analysis of specimens revealed two pathological processes taking place with different localization in the aortic wall as the cause of the atypical coarctation of the aorta: (1) fibrosis/scarification in the tunica media and adventitia compatible with chronic lesions of Takayasu's arteritis (four cases); (2) fibromuscular dysplasia in the tunica media (three cases).

Adolescent↗
PubMed2000

[Early diagnosis of coarctation of the aorta in children: a challenge].

Coarctation of the aorta presents with characteristic and distinctive physical findings. Because delayed detection of severe forms may be fatal and late detection of classic forms is associated with premature cardiovascular disease in adult life, early detection and treatment is important. However, in our survey a few patients in whom aortic coarctation was ultimately diagnosed had the correct diagnosis made by the referring physician. Our survey suggests that an incomplete physical examination explains the diagnostic failure. This survey reaffirms the need for palpation of pulses and proper measurement of blood pressure in all infants and children to facilitate early recognition of coarctation.

Aortic Coarctation↗
PubMedDate not supplied

Transpericardial extra-anatomic intrathoracic aortic bypass conduits in the management of coarctation of the aorta.

Two varied cases of coarctation of the aorta are described, in which transpericardial ascending to descending thoracic aortic conduits were routed around the right atrium, utilizing deep hypothermic circulatory arrest. The approach was through a median sternotomy in two patients. The first case is a 52-year-old female who underwent combined aortic valve replacement for aortic stenosis and repair of aortic coarctation distal to the left subclavian artery. The second case was a fifth time reoperation in a 12-year-old girl with recurrent coarctating. Both patients remain well and asymptomatic.

Aortic Coarctation↗