| Aortic coarctation treated with a self-expandable stent graft | |
| DOI: 10.5606/e-cvsi.2014.92 | |
| Funda Yıldırım, 1 Adnan Taner Kurdal, 1 Alper Özbakkaloğlu, 1 Tülün Öztürk, 2 İhsan İşkesen1 | |
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1Departments of Cardiovascular Surgery, Medical Faculty of Celal Bayar University, Manisa, Turkey 2Departments of Anesthesiology and Reanimation, Medical Faculty of Celal Bayar University, Manisa, Turkey |
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| Keywords: Neosinus; pericardial patching; right ventricular outflow tract stenosis | |
In this article, we presented a 19-year-old patient with juxtaductal aortic coarctation. The coarcted segment was observed with
angiographic study. We planned to implant a self-expandable stent graft. At the angiography laboratory, endovascular aortic stent graft
was implanted through the right femoral artery with direct small femoral incision. Then, we dilated the narrowed stent segment by
balloon catheter. After the procedure, the patient had a significantly dilated aorta distal to the previously coarcted segment. A stent graft
was used to treat coarctation. No access site complications were observed. |
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Aortic coarctation describes wide spectrum of
diseases with the congenital narrowing of any part
of the descending thoracic or abdominal aorta.[1] It
typically refers to the narrowing of the proximal
thoracic aorta at the level of the ductus or ligamentum
arteriosum.[1,2] Surgical treatment has been used
for more than 70 years and coarctation is defined
as primary (native) phenomenon or secondary to
previous corrective surgery.[2] Currently, endovascular
techniques have become more widespread for adult
patients, in particular, and these techniques are less
invasive than conventional surgery. Endovascular
techniques are either balloon angioplasty or primary
stent implantation. Today, catheter intervention is an
established treatment option for adult coarctation with
a good success rate and safety profile.[3] |
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CASE PRESANTATION
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A 19-year-old female patient with juxtaductal aortic
coarctation was admitted to our clinic. Physical
examination revealed no femoral pulses. The upper
extremity blood pressure was measured 160/80 mmHg
and 3/6 systolic murmur was heard over precordial
and interscapular areas. The laboratory test results
were normal. Echocardiography did not reveal any
associated abnormality. The coarcted segment was
demonstrated with the angiographic study (Figure 1).
The sufficient diameter of the coarcted segment and
sufficient length of proximal precoarcted segment was
shown for direct stent graft implantation. Figure 1: Aortic coarctation preoperative angiographic view. We planned to implant a self-expandable stent graft (Medtronic Valiant Thoracic Stent Graft with the Captiva Delivery System, USA). We prepared the patient under epidural anesthesia and bilateral femoral exposure. After the femoral exposure, we observed both of the femoral arteries which were 4-5 mm in diameter due to less blood supply of lower half of the body. At the angiography laboratory, endovascular aortic stent graft was implanted through the right common femoral artery with direct small femoral artery incision (Figure 2). Left femoral artery exposure was used for angiographic control views. We implanted the graft with 22 mm in radius and 112 mm in short and 124 mm with anchoring system in length. Then, we dilated narrowed stent segment by balloon catheter application (Medtronic Reliant Stent Graft Balloon catheter; 12 F) (Figure 3). Figure 2: Aortic coarctation postoperative angiographic view just after direct stent implantation. Figure 3: Aortic coarctation angiographic view during balloon dilatation. After the procedure the patient had a significantly dilated aorta in comparison with the previously coarcted segment (Figure 4). One stent graft was enough to dilate the coarcted segment. There were no access site complications. We observed no complications. Blood pressure in the upper extremity was decreased to normal and the patient was discharged without any complication. At six months, a computed tomography angiographic image was obtained. The preoperative and postoperative images were then compared (Figures 5-7). There was no coarcted segment at the postoperative views. The blood pressure measurements were within normal range. Figure 4: Aortic coarctation postoperative angiographic view. |
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Patients with primary adult aortic coarctation have
a decreased life expectancy, unless treated. Surgical
repair was the only effective treatment option available
in the past and was demonstrated to improve the postoperative treatment of hypertension.[1] These
patients with primary adult aortic coarctation may
suffer from upper extremity hypertension, exercise
intolerance and shortness of breath. These patients
may have many associated cardiovascular comorbidities
such as pulmonary hypertension, left ventricular
hypertrophy and arrhythmias. After surgery, serious
complications requiring revision can be seen. These
are paradox hypertension, postcoarctation syndromes characterized by abdominal complaints, paraplegia,
stroke. Hemothorax, chylothorax, left recurrent
nerve paralysis, left phrenic nerve paralysis, Horner's
syndrome also occur. As late complications restenosis,
ischemia of the left arm and aneurysm formation
at the sugicaly corrected site could be seen. For this
reason, less invasive methods like balloon angioplasty
or stent implantation were preferred for primary
adult aortic coarctation instead of surgery. Since
recurrent coarctation might have seen or complications
such as pseudoaneurysm at the anastomosis or
aneurysm formation around the aortic tissue
after the primary surgical correction, less invasive
endovascular interventions have been described with
good results despite high operative risk.[5] However,
aortic coarctations in older adults have thicker, more
resilient and extensive calcifications which increase
the theoretical risk of rupture with vigorous balloon
dilatation.[4] Furthermore, appropriate patient selection
may decrease complication ratio. Wheatley et al.[1] reported a single center case series with 16 patients in an eight-year period in 2010. The authors observed no perioperative complications and no open surgical conversions, however, further long-term follow-up results were needed. Fink-Josephi et al.[5] reported an endovascular repair of thoracic adult aortic coarctation experiences with 12 patients without complications. In this case report, we performed direct stent implantation, as there was enough diameter to permit the stent placement into the coarcted segment. Then, we opened the self-expandable stent. We also performed balloon dilatation to the previously coarcted segment to prevent mismatch between the post-stenotic dilated segment and coarcted segment diameter and we observed no complication. Balloon dilatation was a simple procedure following the endovascular stent implantation. The patient had no problem related to the coarctation. Hypertension was not observed during the six-month follow-up period. In conclusion, as long-term results of stenting have not been fully reported in the literature, this method should be restricted to selected cases. Our primary criterion for primary stent implantation is the enough diameter of the coarcted segment to pass through endovascular stent graft device, being at least 5-10 mm.
Declaration of conflicting interests
Funding |
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1) Wheatley GH 3rd, Koullias GJ, Rodriguez-Lopez JA,
Ramaiah VG, Diethrich EB. Is endovascular repair the
new gold standard for primary adult coarctation? Eur J Cardiothorac Surg 2010;38:305-10.
2) Turner DR, Gaines PA. Endovascular Management of
Coarctation of the Aorta. Semin Intervent Radiol
2007;24:153-66.
3) Hornung TS, Benson LN, McLaughlin PR. Interventions for
aortic coarctation. Cardiol Rev 2002;10:139-48.
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