Single-Center Experience With Aortic Coarctation Stenting in Adult Patients

Abstract

Objective. Endovascular repair of aortic coarctation (CoA) has become an important tool in the treatment of an expanding patient population. In this study, we present our 10-year experience with endovascular repair of CoA. Methods. Between January 2012 and January 2022, a total of 15 patients were treated at our Institution for CoA with catheter-based techniques. Demographics, intraprocedural data, and follow-up data were retrospectively collected from institutional databases and analyzed. The primary endpoint was technical success and secondary endpoints were intraoperative complications and short-, mid-, and long-term follow-up. Results. Mean age was 44.87 ± 15.52 years (range, 15-64) and 12 patients (80%) were male. Fourteen patients (93.3%) were hypertensive, and 4 patients (26.7%) had a bicuspid aortic valve. Three patients (20%) had undergone open repair in the pediatric age. Fourteen patients (93.3%) received stenting of CoA and 1 patient (6.7%) received thoracic endovascular aortic repair and left subclavian artery stenting for proximal pseudoaneurysmatic dilation and symptomatic restenosis. Mean pretreatment trans-stenotic gradient was 23.25 ± 11.16 mm Hg and posttreatment trans-stenotic gradient was 1.3 ± 1.33 mm Hg. Primary technical success was achieved in 15 cases (100%). One right inguinal hematoma (6.7%) was observed. One patient (6.7%) had an aortic rupture at the left subclavian artery origin after poststent dilation. Mean follow-up time was 34.75 ± 34.38 months. A total of 2 patients had an increased trans-stenotic gradient at long-term follow-up, and 1 reintervention (6.7%) for somatic growth was performed. Conclusions. Endovascular repair of CoA is effective and safe, with excellent mid-term and long-term success rates.

J INVASIVE CARDIOL 2022;34(11):E793-E797. Epub 2022 October 13.

Key words: aortic coarctation, thoracic endovascular aortic repair

Coarctation of the aorta (CoA) is a congenital heart defect that affects about 1 in 2900 live births, even though its prevalence is underestimated.^1-3 CoA is commonly associated with other congenital heart defects, including bicuspid aortic valve, mitral valve stenosis, transverse arch hypoplasia, and genetic syndromes, such as Turner’s or William’s.^4,5 The pathogenesis is unclear, but one of the main theories involves the presence of aberrant ductal tissue in the aortic wall (the "Skodaic theory), leading to increased wall elasticity at the affected segment.^6,7 In addition to congenital defects, CoA can be acquired, having an inflammatory, athero­sclerotic, or iatrogenic etiology.

Clinical presentation largely depends on the site of narrowing in relation to the ductus arteriosus. Neonatal forms are more frequent and severe, and present with hypoperfusion of the lower body, renal dysfunction, or even left heart failure.⁸ Young adult and adult CoA patients present mainly with hypertension, left ventricular hypertrophy, and subsequent congestive heart failure.^6,9

Before the first attempts at endovascular repair of CoA in the early 1980s,^10,11 open repair was the gold standard of treatment.^6,12 Although open repair is still the most common treatment for neonatal or pediatric patients, the 2020 European Society of Cardiology guidelines for the management of adult congenital heart disease favor catheter-based treatment for the initial management of CoA as well as secondary interventions due to elastic recoil.^13,14 In this study, we present the 10-year experience at our institution with thoracic endovascular aortic repair (TEVAR) of CoA in adult patients.

Methods

Study cohort. Patient data were derived from the institutional database, which included patient charts, imaging records, and procedural and discharge notes. Pediatric patients and patients who received conservative or open aortic repair were excluded. The search yielded 15 patients >15 years old who underwent catheter-based treatment for CoA at the Houston Methodist Hospital in Houston, Texas from January 2012 to January 2022. Consent for the collection of information was obtained before the procedure. The institutional review board approved the use of data for this study.

Patient demographics, comorbidities, and preoperative imaging were collected. All patients underwent preoperative echocardiography. Intraoperative information regarding devices, procedures, and radiation data were recorded. Hemodynamic measurements of trans-stenotic gradients (TSGs) were taken intraoperatively before and after treatment with invasive methods. Adjunctive intraoperative imaging techniques, such as fusion imaging or cone-beam computed tomography (CT), were noted.

Intraoperative, short-term (30-day), mid-term (1- to 6-month), and long-term (>6-month) complications were searched for in procedure reports and follow-up notes. Clinical follow-up was carried out by an adult congenital disease specialist periodically. Imaging forms of follow-up included transthoracic echocardiography (TTE), CT angiography, and magnetic resonance imaging (MRI).

Coarctation stenting procedure. The procedures took place in the catheterization laboratory, where access was obtained in the right femoral artery and vein and the right radial artery. Right and left heart catheterization were performed in order to obtain baseline TSG, followed by aortography. Invasive measurement of the left subclavian artery pressure while ballooning its origin was done in select cases in which the subclavian artery might have been covered by a stent. Standard and rotational angiography with fusion imaging (2D-3D/3D-3D overlay) or cone-beam CT with fusion imaging was performed in order to mark important anatomic landmarks, such as the left subclavian origin, point of maximum narrowing, and length of the affected segment. TEVAR was performed with a bare or covered balloon-expandable stent mount on a balloon-in-balloon (BIB) catheter (NuMed). Rapid ventricular pacing was used in short or technically difficult proximal landing zones. Postprocedural TSG was measured; if not satisfactory, additional ballooning or stenting was performed. Final angiographies were obtained and the femoral vascular accesses were percutaneously closed (Figure 1).

Definitions. Primary technical success was defined as successful stent deployment or ballooning with a TSG of <10 mm Hg. We adopted this cut-off due to its widespread use in the literature and because it is the threshold below which intervention is not indicated according to American Heart Association and European Society of Cardiology guidelines.^13,15

Outcomes. The primary study outcome was overall technical success of the procedure. Secondary outcomes included intraoperative complications at short-, mid-, and long-term clinical follow-up.

Statistical analysis. Statistical analysis was carried out with SPSS, version 27 (SPSS) and Excel (Microsoft Corporation). Variables are presented as mean ± standard deviation, median (range), or number (percentage), as appropriate. Long-term follow-up was calculated based on the longest follow-up data available.

Results

Patient demographics. A total of 15 patients underwent endovascular repair for CoA. Mean age was 44.87 ± 15.52 years^15,64 and 12 patients (80%) were male. Fourteen patients (93.3%) were hypertensive and 4 patients (26.7%) had a bicuspid aortic valve. Mean left ventricular (LV) ejection fraction was 53.33 ± 15.7%. Three patients (20%) had undergone open repair in the pediatric age. Two returned for recurrent CoA and one for recurrent CoA and anastomotic pseudoaneurysm. Patient characteristics are illustrated on Table 1.

Procedure details. Fourteen patients (93.3%) underwent stenting for CoA and 1 patient (6.7%) underwent TEVAR and left subclavian artery stenting for proximal pseudoaneurysmal dilation and recurrent symptomatic coarctation. One patient (6.7%) received left carotid-subclavian bypass. The right heart was catheterized in 12 cases (80%). Mean pretreatment TSG was 23.25 ± 11.16 mm Hg and posttreatment TSG was 1.3 ± 1.33 mm Hg. Mean total procedure time was 122.54 ± 61.8 minutes.

Bare-metal balloon-expandable IntraStent Max LD stents (Medtronic) were used in 8 patients (53.4%), with 4 Max LD stents (ev3), and 1 Palmaz XL stent (Cordis). Five (33.3%) covered Cheatham platinum (cCP) stents (B. Braun Medical) were implanted. Median stent length was 12 mm (range, 10-60) and diameter was 36 mm (range, 18-36). Median BIB diameter was 20 mm (range, 16-26). Median sheath size was 14 Fr (range, 8-20). One procedure required the use of 2 c-TAG stent grafts (W.L. Gore & Associates) for exclusion of anastomotic pseudoaneurysm. One case required additional ballooning, BIB 26 mm from 24 mm. Primary technical success was achieved in 15 cases (100%).

One right inguinal hematoma (6.7%) was observed. One patient (6.7%) had an aortic rupture at the left subclavian artery origin immediately after stenting. Thirty-day mortality was 0%. Procedure detail findings are presented in Table 2.

Radiation findings. Mean total fluoroscopy time was 26.97 ± 8.25 minutes, and iodinated contrast dose was 178.09 ± 37.25 mL. Mean dose-area product (DAP) was 112755.936 ± 254187.746 Gy•m² and total radiation dose was 2158.82 ± 1180.82 Gy. A biplane fluoroscopy system was used in 7 cases (46.7%). For C-arm position during stent deployment and ballooning, a median 58° (range, 26-76) left anterior oblique projection was used.

Follow-up. Mean follow-up time was 34.75 ± 34.38 months. The main follow-up imaging modality was echocardiography in 66.7%, CT angiography in 53.4%, and MRI in 46.7%. Three patients (20%) were lost to mid- and long-term follow-up and did not undergo any imaging. Three patients had an increased TSG at long-term follow-up. One of these patients received ballooning for symptomatic recoarctation, while the other 2 patients with restenosis remained stable at 12 mm Hg and 13 mm Hg throughout the rest of the follow-up and were asymptomatic so they did not undergo any additional treatment. One of these patients additionally was found to have a poststenotic dilation of 49 mm at CT angiography 3 years after TEVAR; however, this patient has remained stable. Follow-up details are presented in Table 3.

Discussion

Aortic coarctation can be life threatening or result in severe complications, such as heart failure or endoarteritis.¹⁶ However, today open surgical¹⁷ and endovascular^18-20 treatments can prevent or reduce these complications. Catheter-based treatment has been gaining momentum in the last decades and is now an important treatment for adolescent and adult CoA patients, providing excellent results.^18,19,21,22 Our study explores our 10-year single-center experience with endovascular treatment of 15 adolescent and adult CoA patients.

Hemodynamic criteria are most commonly used to define and classify severity of CoA. A gradient of more than 20 mm Hg or even 10 mm Hg in the presence of collaterals is the cut-off value for treatment according to the 2020 European Society of Cardiology and 2018 American Heart Association guidelines.^14,15 Endovascular therapy is therefore considered effective when a decrease of TSG to < 10 mm Hg is achieved. In our cohort, primary technical success was 100%. In 1 case, the aortic narrowing was not successfully dilated with a 24 mm BIB catheter and further ballooning with a 26 mm catheter was needed. In a systematic review of 45 articles, Hartman et al found that the TSG was reduced from 38.58 mm Hg to 3.93 mm Hg.¹⁹ The authors additionally reported that aortic diameter at the CoA site was increased from 6.43 mm to 15.12 mm. Although hemodynamic parameters are useful for determining treatment outcome, other parameters such as flow patterns and anatomic variability have been shown to influence outcome as well.²³

Commonly reported major intraprocedural complications after TEVAR for CoA include stent migration (2.5%), aortic dissection (0.9%), aortic rupture (0.5%), embolic events (0.6%), and death (0.4%).¹⁹ Erben et al reported 2 aortic ruptures in a multicenter study of 93 patients who underwent endovascular repair of CoA.¹⁸ Both cases were treated with covered stent deployment and 1 of the patients expired. In our cohort, 1 aortic rupture was observed. The patient suffered from a 4-cm ascending aortic aneurysm as well, but a multidisciplinary team had decided against open repair due to his extreme obesity. The patient became hypotensive and eventually went into cardiac arrest. A cCP stent was successfully used to cover the rupture.  Following stenting, he was taken to the operative room for an open repair. The patient never regained consciousness and was subsequently transferred to an outside hospice facility. Even though major complications are rare, it is wise to have covered stents available or used primarily for treatment.

Endovascular treatment of CoA started with intraluminal angioplasty alone and evolved into stenting. Salcher et al observed that the threshold of ≤10 mm Hg was statistically significantly less likely to be achieved by patients undergoing balloon dilation compared with patients undergoing stenting (odds ratio, 0.435;  95% confidence interval, 0.320-0.591; I²=20.3%).²¹ Nowadays, balloon dilation is usually performed for poststenting recoil, as was done in 1 of our cases.

Considering the characteristics of the hyperelastic aortic wall in CoA patients, device selection is very important. Most interventionists favor balloon-expandable stents based on the fact that their radial force can overcome elastic recoil in CoA. Even though bare-metal stents have excellent results in the treatment of CoA, a stent fracture rate of up to 24% has been reported in the COAST II trial.^24,25 Covered stents seem to better distribute radial force to the stent struts, thereby reducing stent fracture.²⁶ Moreover, they offer the possibility to treat higher-risk, narrower lesions as they protect in case of vessel injury. Bare-metal stents can be used in selected patients with high risk of blocking vital aortic branches or in those with milder narrowing.²⁷ Bioresorbable and custom-made stents are also under investigation.^24,28

Although endovascular interventions for CoA have excellent outcomes, regular imaging follow-up is necessary, also considering the impact of CoA on the left ventricle and any associated congenital heart defects such as bicuspid aortic valve and aortic aneurysm.²⁹ Erben et al reported a 10% reintervention rate after a mean 3.2-year follow-up.¹⁸ Nagendran et al reported 2 deaths (4.2%) and 9 reinterventions (19%) after a median follow-up of 5.36 years, whereas the overall survival was 95.8%.²² In our study cohort, the reintervention rate was 6.7%. Two additional patients had a recurrence of their CoA with increased TSG at a mean follow up of 2.9 years. The TSG remained <20 mm Hg and did not require further treatment. Considering the young age of these patients, thoracic magnetic resonance angiography should be considered over CT for follow-up imaging in order to avoid excessive radiation exposure.³⁰ Echocardiography is essential to understand and monitor the impact of CoA and stenting on the heart.

Study limitations. Limitations of this study include the retrospective nature and limited number of patients included. In addition, 3 patients were lost to follow-up immediately after the procedure. Many of the patients did not have preoperative CT angiography, which did not allow for precise comparison of pre- and posttreatment aortic diameters. More studies are needed in order to better validate endovascular treatment on CoA.

Affiliations and Disclosures

From the ¹Section of Vascular Surgery, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy; ²Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas; and ³Siemens Medical Solutions, Inc, Advanced Therapies, Chicago, Illinois.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted July 7, 2022.

Address for correspondence: C. Huie Lin, MD, 6555 Fannin St, Houston, TX 77030. Email: clin@houstonmethodist.org

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