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wire,either0.014″or0.018″,isusedtocrossthelesion(Fig.4.5).Wecommonlyusesoft0.014″work
horse wires such as Asahi Prowater (Abbott Vascular) or Runthrough (Terumo). Next, the diagnostic
catheterisadvancedacrossthelesion.Onceacrossthelesion,the0.014″or0.018″wireisexchanged
for a soft-tipped 0.035 ″ Wholey or Rosen wire for better support before balloon angioplasty and
stenting. Thediagnostic catheter is removed, andballoonangioplasty is performed, typicallywith the
balloondiameterundersizedtothevessel(5-6mmdiameterballoonwithalengththatrangesfrom2040mm). Itisimperative not tocompromise theostium/originofthevertebral ortheinternalmammary
artery.Similarly,caremustbetakentoidentifytheoriginofcommoncarotidarterywhenperformingright
subclavianand/or brachiocephalic arteryintervention.We routinely perform IVUS atthis pointbefore
stentdeploymentforsizingandoptimalvesselpreparation.
3.Itiscommontoproceedwithstentingafterballoonangioplasty,asangioplastyifperformedaloneis
associated with recoil, abrupt closure, dissection, and suboptimal lumen gain.
9,10
For proximal
subclavian lesions, balloon expandable stents are utilized for their radial strength and precise
deployment.Forthemidanddistalvessel,angioplastyaloneispreferred,asstentingishighlyproneto
fracture between clavicle and first rib causing thoracic outlet syndrome physiology. Self-expendable
stentshavereportedlyahighertendencytodevelopstentcompressionandhigherrestenosisrate.
4. It is imperative tocover the ostium of subclavianor brachiocephalic artery by having proximal 2-
3 mmof the stenthang outinthe aortic arch.Precise stentplacement requires goodwire support and
imaginginmultiple orthogonalviews beforedeployment (forleftsubclavianartery, LAOprojectionis
preferred;forrightsubclavianarteryRAOprojectionispreferred).
5. To avoid geographic miss of theostium duringstentdeployment,anadditional stepmaybe usedby
advancingtheguidecatheter orthe long sheathacross thelesion.Thestentisadvancedoverthe wire
withintheguidecatheterandpositionedacrossthelesion.Theguidecatheteriswithdrawn,“unsheathing”
the stent inproper position.Itis imperative not to oversize the stent owing to risk of dissection and
potential catastrophic intrathoracic hemorrhage. Repeat angiogram is warranted to ensure no
complicationsoccurred.IVUSisoptionalpoststentdeployment.
B.Follow-Up
Poststentingpatientsarefollowedat1-,6-,and12-monthintervalsandyearlythereafter.Ourprotocolis
toperform history and physical examination, with bilateral arm blood pressure measurements at each
visit.Ifrestenosisissuspected,colorduplexultrasoundisperformed.
VII.SubclavianTotalOcclusions
A.BrachialApproach
For flush occluded subclavian arterial lesions, a brachial approach is the preferred method. The
techniquevariesfromthefemoralapproach.A6-Frenchshuttlesheathisinsertedintothebrachialartery
carefully,asthebrachialsubclavianarterialjunctionispronetodissection.Deliveryofthesheathoveran
amplatzwire mayreduce therate of dissection.A 0.035″ glidewire supported by either a diagnostic
catheterorglidecatheterisusedtocrossthelesion.Onceacrossthelesion,thetechniquetointerveneis
thesameasoutlinedinthefemoralapproach.Precisepositionofthestentovertheostiumischallenging,
asitisdifficulttovisualizetheostiumwheninjectingfromthearmandonemayhavetorelyonthebony
landmarks/calcification.
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B.CombinedAntegrade(Radial)andRetrograde(CommonFemoral
Access)Approach
Otheroptionistoobtaindualaccessusingcombinedantegrade(radial)andretrograde(commonfemoral
access)approach.Initialimagingisperformedbydualinjectionusinga6Frglidesheathforradialaccess
with a JR4 catheter andan aortogramperformed by pigtail catheter via transfemoral approach. Once
imagingis obtained, a 0.035 ″ glidewire is insertedtothe distal capwithinthe JR4catheter or glide
catheter.Asupportcatheterisusedtohelpcrossthelesion.Oncethewireiswithintheascendingaorta,
repeatimagingshouldbeperformedtoconfirmlocation.Glidewirefromradialaccessissnaredoutofthe
femoralsheath,establishingradialtofemoralrail.Afterestablishingtheradialtofemoralwire,tensionis
applied ateachendbygrasping the wire withhemostats. Femoral sheathis thenadvancedacross the
subclavianlesionandthentheprocedureiscompletedthroughthefemoralaccessasdescribedearlier.
VIII.Outcomes
A.Balloonangioplastyfollowedbystentplacementinthesubclavianarteryhasa5yearprovenpatency
of82%basedonacaseseriesbyWang.11AnotherstudybyHuttletal.onbrachiocephalicangioplasty
showedthatprimaryandsecondarypatencyat10yearswere98%and93%,respectively.12Similarly,
Paukovitsdemonstratedaprimarypatencyrateof98%at2yearsand70%at8yearsin77 innominate
artery angioplasties, thus suggesting that brachiocephalic stenting should be considered as first-line
therapy given the overall high technical success rate and very low rates of procedure complications
(2.6%distalembolization,includingtransientischemicattacksonly).13Restenosisoccursinabout10%
ofpatientswhoundergostenting.
14
B."OUTLINE-END="outline-numbering-end-here
Surgical intervention maybe required for more complex tubular lesions.Varioustechniqueshavebeen
described such ascarotid-subclavianbypass, carotid transposition,oraxillo-axillary bypass surgeries,
whichhaveallmaintainedapatencyrateof70%at5years,withhigherpatencyratesincommoncarotid
bypass(80%)versuslowerpatencyratesinaxillo-axillarybypass(46%).15Ofnote,patientswhohave
symptomatic carotid stenosis should have the carotid stenosis intervened on before intervening for
subclavianstenosis.
C. Patients withhighsurgical riskandunfavorable anatomy for percutaneous interventions should be
treatedmedicallywithantiplatelettherapyandprimarypreventionforothercardiovasculardiseases.
References
1.HennericiM,RautenbergW,MohrS.Strokeriskfromsymptomlessextracranialarterialdisease.Lancet.1982;2(8309):1180-1183.
2.MoranKT,ZideRS,PerssonAV,JewellER.Naturalhistoryofsubclavianstealsyndrome.AmSurg.1988;54(11):643-644.
3.Rodriguez-LopezJA,WernerA,MartinezR,TorruellaLJ,RayLI,DiethrichEB.Stentingforatheroscleroticocclusivediseaseofthe
subclavianartery.AnnVascSurg.1999;13(3):254-260.
4.SchillingerM,HaumerM,SchillingerS,MlekuschW,AhmadiR,MinarE.Outcomeofconservativeversusinterventionaltreatmentof
subclavianarterystenosis.JEndovascTher.2002;9(2):139-146.
5.OchoaVM,YeghiazariansY.Subclavianarterystenosis:areviewforthevascularmedicinepractitioner.VascMed.2011;16(1):29-34.
6.OsbornLA,VernonSM,ReynoldsB,TimmTC,AllenK.Screeningforsubclavianarterystenosisinpatientswhoarecandidatesfor
coronarybypasssurgery.CatheterCardiovascInterv.2002;56(2):162-165.
7.LobatoEB,KernKB,Bauder-HeitJ,HughesL,SulekCA.Incidenceofcoronary-subclavianstealsyndromeinpatientsundergoing
noncardiacsurgery.JCardiothoracVascAnesth.2001;15(6):689-692.
8.PatelSN,WhiteCJ,CollinsTJ,etal.Catheter-basedtreatmentofthesubclavianandinnominatearteries.CatheterCardiovascInterv.
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2008;71(7):963-968.
9.BachmanDM,KimRM.Transluminaldilatationforsubclavianstealsyndrome.AJRAmJRoentgenol.1980;135(5):995-996.
10.ZeitlerE,RichterEI,RothFJ,SchoopW.Resultsofpercutaneoustransluminalangioplasty.Radiology.1983;146(1):57-60.
11.WangKQ,WangZG,YangBZ,etal.Long-termresultsofendovasculartherapyforproximalsubclavianarterialobstructivelesions.
ChinMedJ(Engl).2010;123(1):45-50.
12.HuttlK,NemesB,SimonffyA,EntzL,BercziV.Angioplastyoftheinnominatearteryin89patients:experienceover19years.
CardiovascInterventRadiol.2002;25(2):109-14.
13.PaukovitsTM,LukacsL,BercziV,HirschbergK,NemesB,HuttlK.Percutaneousendovasculartreatmentofinnominateartery
lesions:asingle-centreexperienceon77lesions.EurJVascEndovascSurg.2010;40(1):35-43.
14.FilippoF,FrancescoM,FrancescoR,etal.Percutaneousangioplastyandstentingofleftsubclavianarterylesionsforthetreatmentof
patientswithconcomitantvertebralandcoronarysubclavianstealsyndrome.CardiovascInterventRadiol.2006;29(3):348-353.
15.SalamTA,LumsdenAB,SmithRB.Subclavianarteryrevascularization:adecadeofexperiencewithextrathoracicbypassprocedures.
JSurgRes.1994;56(5):387-392.
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C H A P T E R 5
CoarctationoftheAorta
ChandniPatelMD
KurtBjorkmanMD
JeremyD.AsnesMD
I.Introduction
A.Coarctation
II.CoexistingDisease
A.Occurrence
B.Anomalies
III.NaturalHistory
IV.PresentationandExaminationFindings
A.Presentation
B.ExaminationFindings
V.Evaluation
A.TestingandImaging
B.AnatomicConsiderations
VI.IndicationsforTreatment
VII.GoalsofTherapy
VIII.TreatmentOptions
A.MeasuresofSuccess
B.Surgery
C.InterventionRecommendations
IX.PercutaneousTreatmentOptions
A.BalloonAngioplasty
B.TechniqueandProceduralConsiderationsforBalloonAngioplasty
C.ComplicationsFromBalloonAngioplasty
D.StentAngioplasty
E.TechniqueandProceduralConsiderationsforStentAngioplasty
F.ComplicationsFromStentAngioplasty
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V.Follow-up
KeyPoints
■Coarctationoftheaortamaybefirstidentifiedinadolescenceoradulthoodwith
hypertensionoftenbeingthefirstpresentingsign.
■Interventionforcoarctationshouldbeapproachedcautiouslyandmethodically.
■Fornativecoarctation,currentrecommendationssuggestamultidisciplinaryapproach
incorporatinginputfromsurgeons,cardiologists,andinterventionalistswithadultcongenital
heartdiseaseexpertisetodeterminesurgicalversuscatheter-basedintervention.
■Forrecurrentdiscretecoarctation,guidelinesfavorpercutaneouscatheterinterventionover
surgery.
■Stentangioplastyhasbeenshowntohavesuperioroutcomesandlowercomplicationrates
ascomparedwithbothballoonangioplastyandsurgery.
■Coveredstentsshouldbeavailableduringinterventionalproceduresintheeventofserious
aorticwallinjury.
■Giventheriskofaorticwallinjurywithcatheter-basedinterventionforcoarctation,routine
follow-upwitheitherCTangiographyorMRangiographyshouldbeperformed.
I.Introduction
A. Coarctation of the aorta describes a wide variation of anatomic narrowing of the aorta, most
commonlyoccurringasadiscretelesionintheproximalthoracicaortaoppositetheinsertionsiteofthe
ductusarteriosis.1However,evenwhendiscrete,coarctationisconsideredtobepartofageneralized
arteriopathy.2Itisoneofthemorecommoncongenitallesions,accountingfor5%-10%ofallcongenital
heartdisease.Geneticinfluencesoncoarctationhavelongbeensuspectedwithawell-documentedmale
predominance of disease withanincidence ratio of 1.7:1.3 This genetic link is further evidenced by
coarctation appearing in 35% of patients with Turner syndrome (45X). NOTCH1 and MCTP2 have
recentlybeenrecognizedaspossiblelocifordisease.
4,5
B. Permutations of this disease exist not only in location but also in length, severity, coexisting
conditions, time of presentation, and complications.1 Rarely, coarctation involves the ascending or
abdominalaorta.6Althoughmostoftendiagnosedininfancyorchildhood,aorticcoarctationmayfirstbe
identified in adolescence or adulthood. Furthermore, with increasing survival and patient longevity,
significant rates of residual coarctation, as well as recurrence postintervention, are seen well into
adulthood.
7-10
C.Hypertension of the aorta and its branches proximal to the obstructed aortic segment is the most
obvious consequence of this disease. However, coarctation-associated hypertension is only one
componentofacomplexarteriopathicdisease.Moreover,althoughitistemptingtoconsidertreatmentof
coarctationasasimpleproceduredirectedatreliefofaorticobstructionandhypertension,thecareofthe
patientwith aorticcoarctationrequiresalife-long, oftenmultidisciplinaryapproachthatshouldinclude
expertsinadultcongenitalheartdisease.
II.CoexistingDisease
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A.Occurrence
1.Coarctationmostcommonlyoccursinconjunctionwithothercongenitalheartlesionsincludingaortic
arch hypoplasia, ventricular septal defects (VSDs), patent ductus arteriosus, transpositionof thegreat
arteries,atrioventricularcanaldefects,andleft-sidedobstructivelesionsincludingabnormalitiesofthe
mitralvalveandthesubaorticregion.
11
2.Bicuspidaorticvalveisseeninmorethan50%ofaffectedpatients.
12
Inaseriesof500patientswith
coarctationundergoingMRIassessment,only14%hadisolatedcoarctation.
13
B.Anomalies
a. Coarctationisalsoassociatedwithextracardiacvascularanomaliesincludingimportantvariations
in brachiocephalic artery anatomy, a robust collateral arterial circulation, and intracranial
aneurysms.
1,11,14
b. Arterial collaterals may arise from the internal thoracic and subclavian arteries, thyrocervical
trunks,andvertebralandanteriorspinalarteriesandprovidebloodsupplytothedescendingaorta,
bypassingtheobstructioncausedbythecoarctationitself.15Theaortic wallitselfisabnormaland
predisposedtodissectionandrupture.
16
III.NaturalHistory
A.ThenaturalhistoryofuncorrectedcoarctationoftheaortawasdescribedbyCampbellin1970after
reviewingtherecordsof465patientswhohadsurvivedthefirstyearoflife.
1.Ofthese,therewasameanageofdeathat34years,and75%ofpatientsdiedbyage46years,withthe
most common causes of death including congestive heart failure (26%), aortic rupture (21%),
endocarditis(18%),andintracranialhemorrhage(12%).
3
B.Lifeexpectancyissignificantlyimprovedwithintervention,butstillnotablyreducedfromnonaffected
populationswithsurvivalratesof72%at30yearsafteroperationinthoseoperatedonatmedianageof
16years,and81%survivalat50yearsaftersurgeryinthoseoperatedonbeforetheageof5years.
17,18
C.Inpatientswhohavehadcorrectiveintervention,themostcommoncausesoflatedeatharecoronary
artery disease, sudden cardiac death, heart failure, cerebrovascular accidents, and ruptured aortic
aneurysm.17Thus,interventionisessentialtopreventsignificantmorbidityandmortality.
IV.PresentationandExaminationFindings
A.Presentation
1. The most common presenting sign of disease in the patient with aortic coarctation is systolic
hypertension,andperhapsthemosteasilyidentifiedfindingisadifferentialbetweentheupperextremity
andlowerextremitysystolicbloodpressure.
19
a. Patientspresentingwithcoarctation-associatedhypertensionfallintooneofthethreecategories:
thosewith“native”coarctationforwhichnopriorinterventionhasbeenundertaken;thosewith
residualorrecurrentobstructionatoradjacenttoasiteofpriorcatheterorsurgicalintervention,so
calledrecurrentcoarctation;andthosewithwell-repairedcoarctation,noresidualaorticarch
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obstruction,andpersistenthypertension(Fig.5A.1).
FIGURE5A.1 A,Nativecoarctationina40-year-oldmanwhohadpreviouslyundergoneascendingaorta
andaorticvalvereplacement(narrowestdiameter4.5mm).B,4.5-cm-longCheathamPlatinumCovered
Stentpremountedon22mmballoon-in-ballooncatheter;deploymentwithinnerballooninflated.C,Outer
ballooninflatedat3atm.D,Finalangiogramfollowingcoveredstentangioplasty.
b. Regardlessofwhichcategorytheyarein,patientsareoftenasymptomatic.Rarely,theymaypresent
withheadache,epistaxis,claudication,aorticdissection,orheartfailure.
16,20
Wewilldiscussthe
managementofthosepatientswithnative,residual,andrecurrentobstructioninthischapter.
2.Notdiscussedinthischapteristhefarmoreuncommonpresentationofapatientwithcomplicationsof
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aorticaneurysmrelatedtoapriorcoarctationrepair.
B.ExaminationFindings
1.Asidefromhypertension,notablephysicalexaminationfindingsmayincludediminishedanddelayed
femoralpulsesascomparedwiththeradialpulse(pulsusparvusettardus)aswellasacardiacmurmur.
2.Asystolicejectionmurmurfromthecoarctationmaybeheardintheleftuppersternalborder,atthe
baseoftheheart,andintheback.Inaddition,continuousmurmursmaybeheardovertheanteriorchest
wallandbackinpatientswitharobustcollateralarterialsystem.
3. Associated lesions suchas aortic valve stenosis, VSDs, or mitral stenosis will produce their own
distinctmurmursaswell.
1
4.Surgeryforcoarctationmaybeperformedfromaleftorrightlateralthoracotomy,or fromamedian
sternotomy(mostofteninthesettingofconcomitantcardiacdiseaseorarchhypoplasia).Surgicalscars
willhelpguideanunderstandingoftheapproachtakeninpatientswithoutawell-knownhistory.
V.Evaluation
A.TestingandImaging
1.Bloodpressureassessmentinallfourextremities
2.Fullphysicalexaminationincludingidentificationofscarsrelatedtopriorsurgery
3. Echocardiogram to assess associated congenital cardiac disease and/or surgical repairs and
myocardialfunction
4. Thoracic CTA (CT angiography) or MRA (MR angiography) for detailed assessment of the entire
thoracicaortaanditsbranches
5. Imaging of the intracranial vasculature (CTA or MRA) is recommended to exclude coexisting
aneurysms,whichcanbeseeninupto10%ofpatientswithcoarctation
16,21
6.In theolderadult orothersatriskforperipheralvasculardisease,considerationshould begivento
assessmentofthefemoralandiliacarteries(CTAorMRA)
B.AnatomicConsiderations
1.Notably,3%-4%ofpatientswithcoarctationwillhaveanaberrantrightsubclavianarteryarisingfrom
the descending aorta distal to the obstruction, complicating the assessment of a blood pressure
differential.
2. Furthermore,inpatients witharobustarterial collateral circulation, the blood pressuredifferential
maybereduced,maskingtheseverityoftheaorticobstruction.
3.Inaddition,surgicalapproachestocoarctationmayincludesacrificeoftheleftsubclavianarteryasa
componentoftherepair(subclavianflaptechnique).
a. Inthesepatients,thebloodpressureintheleftarmisunreliable.
b. Owingtoacombinationofanatomicvariationand/orsurgicalrepair,thereisnoreliable,
noninvasivemeansofassessingthesystolicbloodpressureproximaltoasegmentofnarrowedaorta.
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VI.IndicationsforTreatment
American and European guidelines for the treatment of adult patients with congenital heart disease
include specific recommendations regarding the treatment of aortic coarctation.
2,16
A summary of
indicationsforinterventioncanbefoundinTable5A.1.
Table5A.1
IndicationsforInterventioninPatientsWithAorticCoarctation
■Peak-to-peakcoarctationgradient≥20mmHg
■Peak-to-peakcoarctationgradient<20mmHginthepresenceofanatomicimagingevidenceofsignificantcoarctationwith
radiologicalevidenceofsignificantcollateralflow
■Pathologicbloodpressureresponsetoexercise
■≥50%luminalnarrowingrelativetotheaorticlumenatthelevelofthediaphragm(independentofbloodpressuregradient)
VII.GoalsofTherapy
A.The primary goal of any interventional therapy for aortic coarctation is to normalize the luminal
diameter of the narrowed segment ofthe aorta andtherebyeliminate the pressure gradient across the
coarctation.Inmostbutnotallpatients,thiswillleadtoimprovementinhypertensionandadecreasein
theneedforantihypertensivemedication.
B.Determining the appropriate or “normal” targetdiameter of the aorta ina patient withcoarctation
requiresassessmentofthatindividual’saorticdimensionsfromthetransversearchtothedistalthoracic
aortaatthelevelofthediaphragm.Thereisoftenaneurysmaldilationoftheascendingaorta,particularly
whenabicuspidaorticvalveispresent.Theremayalsobeassociatedtransversearchhypoplasia,which
inandofitselfcanleadtohypertensionintheproximalarchandascendingaortaevenaftersuccessful
treatment ofadiscretecoarctation.Typically, thereisaneurysmaldilation oftheaortajustdistal tothe
coarctation,butthedimensionsofaortaatthelevelofthediaphragmarepreserved.Thus,thediameterof
theaortaatthediaphragmisoftenusedasatherapeutictarget.
C.Garcieretal.reportedaorticlumendimensionsmeasuredbyMRIin66healthyadultswithamean
ageof44.5years(range19.3-82.4y).22Themeandiameterfromthedistalaorticarchtothemidthoracic
aortarangedfrom25mm(range16.4-35mm)atthedistalarchto22.7mm(range13.8-32mm) atthe
level of the leftventricle.22 Because ofthe coexistingaortopathy, these dimensions maynot applyto
individualswithaorticcoarctation.However,whenconsideringtherapyinayoungpatientwithgrowth
potential,theymustbekeptinmind.
VIII.TreatmentOptions
A.MeasuresofSuccess
1. The successful treatment of aortic coarctation must be measured across multiple domains. In the
hypertensive patient withnative or recurrent coarctation, the overarching goal is reduction of systolic
bloodpressure.
a. However,itiswellknownthatrestingandexercisehypertensioniscommoninthispopulation,even
intheabsenceofpersistentaorticobstruction.
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b. Furthermore,hypertensioncanbepartiallymitigatedwithpharmacologictherapiesinsomepatients
withaorticobstruction.
c. Thus,measuresoftherapeuticsuccessmayincludenotonlyangiographicimprovementinaortic
lumensizebutalsoreductioningradient,reductioninbloodpressureatrestand/orwithexercise,
reductioninsymptoms(whenpresent),andreductioninantihypertensivemedicationrequirements.
2.Measuresofproceduralsuccessincludenotonlytherapeuticsuccessbutalsotheabsenceofsignificant
procedure-relatedmorbidityandmortalityincludingaorticwallinjuryandaneurysmformation.
B.Surgery
1. Surgical repair of aortic coarctation may be accomplished through several different approaches
including coarctectomy with direct end-to-end anastomosis or extended end-to-end anastomosis,
interpositiongraftplacement,bypassgraftplacement,andsubclavianflaporpatchaortoplasty.Inpatients
with recurrent coarctation, understanding the initial surgical approach is critical to understanding the
causeofrecurrentobstructionandhowtobestmanageit.
2.Currentguidelinesrecommendsurgicalinterventionforlong-segmentrecoarctationandcoarctationin
thesettingofaorticarchhypoplasia.
16
a. Furthermore,theseguidelinesrecommendthatsurgerybeperformedbysurgeonswithexpertisein
congenitalheartsurgery.
b. Withregardtodiscretenativecoarctation,guidelinesdonotspecifyapreferenceforsurgeryor
transcatheterapproach,butratherrecommendamultidisciplinaryapproachincorporatinginputfrom
surgeons,cardiologists,andinterventionalistswithadultcongenitalheartdiseaseexpertise.
c. Forrecurrentdiscretecoarctation,guidelinesfavorpercutaneouscatheterinterventionoversurgery.
C.InterventionRecommendations
Surgerycarriesuptoa10%reinterventionriskforolderchildrenandadults23andinonestudyspanning
severaldecadeswasassociatedwithaperioperative mortalityof4.5%.17Thus,therehasbeenashift
recently toward percutaneous approaches (balloon angioplasty or stent placement) for primary
intervention in adults with uncomplicated native coarctation.
16,23,24
In patients with recoarctation, the
general consensus favors, with rare exception, the transcatheter approach regardless of the age. In
particular,stent angioplastyhas come into favor as theinterventionofchoice inadultswith native or
recurrentcoarctationbecauseofitssuperior outcomesandlower complicationratesascomparedwith
both balloon angioplasty and surgery.25 We describe in the sections that follow the available
percutaneousoptionsfortreatmentofcoarctationoftheaorta.
IX.PercutaneousTreatmentOptions
A.BalloonAngioplasty
1. Balloonangioplasty can resultin hemodynamic and angiographic improvementsin bothnative and
recurrent coarctation.Animal studies have demonstrated thatsuccessful balloon angioplasty for aortic
coarctation results in tears of the aortic intima.26 Achieving a successful tear generally requires
expansionofthestenoticlesionbytwotothreetimesitsinitialdiameter.
2.Thegradientreliefachievedwithballoonangioplastyislesspredictable,andtheriskofundesirable
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