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CARDIOVASCULAR RADIOLOGY Table of Contents   
Year : 2000  |  Volume : 10  |  Issue : 3  |  Page : 155-156
Endovascular treatment of coarctation of aorta


1 Dept of Radiology, Apollo Hospital, Chennai, India
2 Dept of Cardiology, Apollo Hospital, Chennai, India

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Keywords: coarctation, aorta, endovascular treatment

How to cite this article:
Ahmed N I, Mao R, Halbe S. Endovascular treatment of coarctation of aorta. Indian J Radiol Imaging 2000;10:155-6

How to cite this URL:
Ahmed N I, Mao R, Halbe S. Endovascular treatment of coarctation of aorta. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Sep 15];10:155-6. Available from: http://www.ijri.org/text.asp?2000/10/3/155/30585
Coarctation of aorta (COA) may present in infancy, childhood or even in later life. Till recently surgery was the only therapeutic option available; however, during the last decade, endovascular treatment of COA using balloon dilatation and stenting is proving to be successful, with less morbidity.

We report here the successful treatment by angioplasty and stenting of COA in a thirty-one- year old man.


   Case Report Top


A man aged 31 presented with symptoms of breathlessness on exertion. This problem had persisted for about two years. He was detected to be hypertensive two and a half years ago and had been on treatment, with irregular compliance. On examination, the salient features were that his lower limb pulses were feeble. The blood pressure in the right upper limb was 160/90 mm of Hg and in right lower limb 110/90mm of Hg. Hence clinically he was diagnosed to have congenital COA. There was no associated cardiac anomaly.

An angiogram showed a localized COA distal to the origin of the left subclavian artery with poststenotic dilatation [Figure - 1] and the gradient across the coarctation was 65 mm of Hg. The diameters of the pre and post coarct segment of the aorta and the coarcted segment were 19mm, 22mm and 6 mm respectively.

Through the right brachial route, a 6F-pigtail catheter was positioned above the coarctation segment for continuous arterial pressure monitoring and for check angiograms for proper placement of the balloon and the stent. A 12F sheath was introduced through the right femoral route and the coarct segment was crossed using a Nycomed angioplasty guide wire. Since, it was a severe coarctation (gradient of 65mm of Hg), it was decided to do a primary stenting of the lesion. A Palmaz Schatz P 5014 stent (50 mm in length with a maximum diameter of 14mm) was manually crimped over a 60 x 20mm Maxi-LD balloon and was deployed across the coarctation at 4 atmospheric pressure (ATM) for 1 minute [Figure - 2]. In view of the post-stenotic dilatation that was present, a small waist was deliberately maintained in order to prevent stent migration.

Subsequently a 40 x 25mm Maxi-LD balloon was positioned across the distal (post-coarctation) segment of the stent and inflated to 3.5 ATM in order to approximate the stent to the aortic wall.

Post-procedure angiogram showed satisfactory dilatation of the coarcted segment (now 8 mm in diameter) [Figure - 3]. The gradient across the coarctation dropped to zero after stenting. The patient was normotensive on discharge and on follow-up for six months without the use of antihypertensive medication.


   Discussion Top


Balloon angioplasty provides an effective therapeutic alternative to surgery in native COA; the initial and long term results are better in children and older adults as compared to infants [1],[2],[3],[4]. It can also be performed in patients where surgical relief of the obstruction is incomplete.

The mechanism by which angioplasty enlarges the internal aortic diameter is by the production of intimal and medial tears. In order to perform the angioplasty, it is imperative to measure the diameters of the coarcted segment, proximal aorta and distal aorta from the aortogram. The angioplasty balloon is chosen with a diameter 2.5 - 3.0 times that of the narrowed segment but should be less than 1.5 times the diameter of the aorta proximal to the coarctation [5].

The known major complications of balloon angioplasty are sudden death due to ventricular fibrillation and aortic rupture [6] and aneurysm formation due to weakening of the aortic wall due to an intimal tear [7]. To prevent these complications it is recommended that

i. Manipulation of guide wire and catheters through the site of a freshly dilated aortic coarctation should be avoided.

ii. Balloon size should not be greater than that of the aorta.

iii. Inflation pressure should be closely monitored during the procedure.

iv. The tip of the balloon catheter should be in the mid-aortic arch and not in the ascending aorta [3].

Paradoxical hypertension and occlusion of the femoral artery are other complications associated with the procedure.

Stent implantation is an excellent alternative treatment to surgical correction. In severe coarctation of aorta, it provides excellent immediate and long term results in children and young adults. However, if done at too early an age, restenosis by intimal proliferation may develop. Stents implanted in the aorta become incorporated within the aortic wall and it may be possible to further dilate them as in growing animals by future angioplasty [8]. Stents eliminate the gradient and this was observed in our patient also, where the gradient was reduced to zero after stent implantation. Stent implantation has minimum morbidity and no mortality. Late restenosis and possible aneurysm formation are less likely to occur after stent implantation in view of the ample luminal diameter and the high velocity flow [9].

 
   References Top

1.Fletcher SE, Nihill MR, Grifka R, O'Laughlin MP, Mullins CE. Balloon angioplasty of native coarctation of the aorta: midterm follow up and prognostic factors. J Am Coll Cardiol 1995; 25:730-734.   Back to cited text no. 1    
2.Mendelsohn AM, Lloyd TR, Crowley DC, Sandhu SK, Kocis KC, Beekman RHI. Late follow up of balloon angioplasty in children with a native coarctation of the Aorta. AM J Cardiol 1994; 74:696 - 700.   Back to cited text no. 2    
3.Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctation. Ann Thorac Surg 1991; 52:594-600   Back to cited text no. 3    
4.Waldman JD, Karp RB. How should we treat coarctation of the aorta? Circulation 1993;87:1043-1045   Back to cited text no. 4  [PUBMED]  
5.Bass JL, Rocchini AP, Zhong Qian. Catheter directed interventional procedures in children. In: Wilfrido R. Castaneda - Zuniga, Ed. Interventional Radiology-Volume 1. 3rd ed. Baltimore: Williams and Wilkins, 1997:1019.   Back to cited text no. 5    
6.Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: Results of valvuloplasty and angioplasty of Congenital anomalies. Registry. Am J Cardiol 1990; 65:790-792.   Back to cited text no. 6    
7.Shaddy RE, Boucek MM, Sturtevant JE et al . Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation 1993; 87:793-799.   Back to cited text no. 7    
8.Suarez de Lezo J, Pan M, Romero M et al . Immediate and follow up findings after stent treatment for severe coarctation of aorta. Am J Cardiol 1999; 83: 400-406.   Back to cited text no. 8    
9.Ledesma M, Diazy Diaz E, Alva Espinosa C et al . Stent in aortic coarctation. Immediate results. Arch Inst Cardiol Mex 1997; 67:399-404.   Back to cited text no. 9    

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Correspondence Address:
N Iqbal Ahmed
Dept of Radiology and Imaging Science, Apollo Hospital, 21, Greams Lane, Off Greams Road, Chennai 600 006
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

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