Download Endovascular treatment of aortic coarctation

M I L E V I VA N M D
S P E C I A L H O S P I TA L F O R S U R G I C A L D I S E A S E S “ F I L I P V T O R I ”, S K O PJ E
Definition and anatomy
Introduction
• CoAo:
– Simple definition: stenosis mostly in the thoracic descending
aorta
– Complex congenital heart disease
• Significant anatomical variability
• Diverse associated lesions
• Histological abnormalities of the aorta
Clinical presentation
Class I
1. Every HTA pt have the brachial and femoral pulses palpated simultaneously .
Bilateral brachial artery blood pressures and one popliteal artery blood pressures
should be measured (Level of Evidence: C)
2. Initial imaging and hemodynamic evaluation by TTE, including suprasternal
notch acoustic windows, is useful in suspected aortic coarctation. (Level of
Evidence:B)
3. Every patient with coarctation (repaired or not) should have at least 1
cardiovascular MRI or CT scan for complete evaluation of the thoracic aorta and
intracranial vessels. (Level of Evidence: B)
*ACC/AHA 2008 Guidelines for Adults With CHD
Diagnostics procedures
Guidelines for Interventional and Surgical
Treatment of Coarctation of the Aorta in adults
Class I
1. Intervention for coarctation is recommended in the following circumstances:
a. Peak-to-peak coarctation gradient greater than or equal to 20 mm Hg. (Level
of Evidence: C)
b. Peak-to-peak coarctation gradient less than 20 mm Hg in the presence of
anatomic imaging evidence of significant coarctation with radiological evidence of
significant collateral flow. (Level of Evidence: C)
2. Choice of percutaneous catheter intervention versus surgical repair of native
discrete coarctation should be determined by consultation with a team of ACHD
cardiologists, interventionalists, and surgeons at an ACHD center.(Level ofEvidence:C)
3. Percutaneous catheter intervention is indicated for recurrent, discrete coarctation and a peak-to-peak gradient of at least 20 mm Hg. (Level of Evidence: B)
4. Surgeons with training and expertise in CHD should perform operations for previously repaired coarctation and the following indications:)
a. Long recoarctation segment. (Level of Evidence: B)
b. Concomitant hypoplasia of the aortic arch. (Level of Evidence: B)
Class IIb
Stent placement for long-segment coarctation may be considered, but the
usefulness is not well established, and the long-term efficacy and safety are
unknown.
ACC/AHA 2008 Guidelines for Adults With CHD
Management of native CoAo
Percutaneous treatment of congenital heart
diseases in Filip Vtori Hospital (2003-2014)
Treatment of congenital heart defects
180
160
156
140
120
100
80
69
54
60
40
28
2009-2014
25
24
20
6
2
Aortic
stenosis
Coronary AV
fistula
0
ASD
Pulmonary
stenosis
PDA
VSD
PFO
Coarctation
of the aorta
Balloon angioplasty - infant and children
(<8yrs/25kg), feasible anatomy, n=14
Indications for stenting of CoAo
• Patients > 8 yrs (> 25-30 kg)
• No intracardiac lesion
• Native CoAo or Recurrent CoA (post surgical or balloon)
• Discrete or segmentar CoAo
• Normal or hypoplasic isthmus
• Mild CoA (SG < 20 mmHg) with left ventricular
hypertrophy and/or systemic arterial hypertension
Stent implantation (>8yrs/ 25 kg, feasible anatomy), n=10
Miscellaneous CoAo
Miscellaneous CoAo
Miscellaneous CoAo
Results (2009-2014)
Patients #
24
Male
Female
17 (71%)
7 (29%)
Age
2mo – 49y
Treatment:
Baloon
Stent
14 (58%)
10 (42%)
Mean PG (before interv.)
Mean PG (after interv.)
56mmHg (35-85)
19mmHg (10-29)
Isolated
Combined (VSD, PDA)
19 (79%)
5 (21%)
Complications
1 (4%)
Our complications
Case #1
 Patient T.J., male, age 14y
 Presentation: headaches,
↑BP(190/120mmHg), ↓femoral
pulse
 Echocardiography: Coarctation PG
50mmHg, LVH (IVS 16mm)
 Balloon predilatation (Tyshak
10/30mm); Bip Balloon 22/45mm
22P 8atm 16mm; stent CP8Z39
Case #2
 Patient A.N., male, age 19y
 Presentation: asymptomatic
↑BP(160/100mmHg)
 Echocardiography: Coarctation
PG 40mmHg, LVH (IVS 14mm)
 CP stent 8Zig 39mm; pre
dilatation balloon Tyshak II
22/40mm
Case #3
 Patient N.N., female, age 49y
 Two years prior ACBPx1, ASD
Closure + TKR; AFF; HTA; HLM
 Coarctatation PG 40mmHg
 Covered CP stent 8 Zig 28mm,
18mm
N.N. 49yrs.
Summary and Follow-Up
Class I
1. Lifelong cardiology follow-up is recommended for all patients with aortic coarctation, repaired or not. (Level of
Evidence: C)
2. Patients with surgical repair or percutaneous intervention for coarctation should have at least yearly followup. (Level of Evidence: C)
3. Late postoperative thoracic aortic imaging should be performed to assess for aortic dilatation or aneurysm
formation for all pts. (Level of Evidence: B)
4. Patients should be observed closely for systemic arterial hypertension, which should be treated aggressively
after recoarctation is excluded. (Level of Evidence:B)
5. Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less (Level of
Evidence: C)
Class IIb
1. Routine exercise testing may be performed at intervals determined by consultation with the regional ACHD
center. (Level of Evidence: C)
ACC/AHA 2008 Guidelines for Adults With CHD
Best option for patient, MD and hospitals
 Age >8yrs/25 kg
 Good anatomy
 No concomitant lesions
 Stenting of aorta
Thanks for your attention