Intervention of Aortic Coarctation:

from Angioplasty to StentGejun Zhang, Zhongying Xu, Shiliang JiangCardiovascular Institute & Fuwai Hospital

CAMS &PUMC, Beijing

Prevalence

• Western: 7-14% in CHD• Chinese: 0.6-1.6% in CHD• Gender: male: female2.1 ： 1(Chinese)

Pathology

• Location: most in aortic isthmus• 2 ~ 5mm （ 75 ％）• Discrete, tubular or long• Concentric or eccentric • Degeneration, or necrosis in aortic wall

Pathology

From Y. Ho

Pathology

Pathophysiology

• Vessel diameter decrease>50%peak systolic gradient >20 mmHg

• Secondary hypertension• Collaterals• Aneurysm formation ： 10 ％ before 20

yrs ； 20 ％ before 30 yrs, ……• Complex CoA

Diagnostic Imaging

• X-ray plain film• Echocardiography• CT• MRI• Angiography

X-ray Plain Film

Echocardiography

MDCT

3D Reconstruction of MDCT

MRA

Balloon Angioplasty• 1979, Sos et al ； 1982, Lock et al• Indication ： native CoA/ recurrent CoA,

SPG>20mmHg ， discrete• Machanism ： tear and stretch of aortic wall• Balloon catheter ： low profile• Advantage: suitable for all patients of any

age• Disadvantage: uncontrolled tear and stretch

of vessel wall

Balloon Angioplasty

Approach ：– Angiography and catheterization– Measurement– Diameter of Balloon ： 2 － 4 times of

diameter of CoA/diameter of normal aortic isthmus ； not above the diameter of descending aorta (diaphragm level)

– 3 － 8 atm ， 5 － 15s ， could repeat for 2－ 4 times ， interval 5 min

– Heperinized; aspirin for 3-6 months

Balloon Angioplasty

• Effective and safe (immediate result)• Complications

– restenosis(5-15%)– aneurysm: (5-40%)– dissection: (1-3%)– femoral artery injury and thrombosis– death ： 0.7 ％

Balloon Angioplasty

• neonates and infants with native CoA – primary surgery– angioplasty only for palliation

• children with native CoA < 30kg– primary surgery in children with complex aortic

arch anomaly– primary angioplasty in children with discrete CoA

• recurrent CoA– Angioplasty or stent

Balloon Angioplasty

Children, male, 4yr and 6month, PG ＝ 70mmHg

Balloon Angioplasty

扩张后 PG ＝ 28mmHg

Balloon Angioplasty

SV, hybrid therapy, Glenn shunt+CoA balloon angioplastySPG: 45mmHg15mmHg

Implantation of Stent• 1991 O’Laughlin, Lock etal• Targets ：

– Getting more diameter– Less vessel wall injury ， less complication– Preventing recoil/ restenosis

• Indication ：– native CoA or recurrent CoA, PSG>20mmHg– children >30 kg, adolescent and adult

• Disadvantage:– Large sheath– Expensive

Implantation of Stent

• Stent:– Bare stent: CP stent; Palmaz stent(8 － 10

series); Genesis XD stent ； eV3 LD stent– Covered stent: covered CP stent

• Balloon– BIB catheter; Z-Med balloon

• Guide wire ： supper stiff (260cm)• Sheath ： Mullins sheath or …

Bare Stent for CoA

Covered CP Stent and BIB Catheter

Implantation of StentApproach• Locating stiff guide wire in ascending aorta• Push sheath across the guide wire• Balloon: length≥stent length; diameter=diameter of

aorta proximal to CoA segment or +1-2mm• Mount stent to balloon• Draw sheath back and leave stent• confirm• Inflation of balloon to expand stent• Deflation of balloon and draw back into sheath• Angiography and catheterization

Implantation of Stent

male ， 19yrs ，PG ＝ 80mmHg

Implantation of Stent

Implantation of Stent

Implantation of Stent

PG=13mmHg

Implantation of StentCoA +PDA （ female ， 45 yrs ）， PG ＝ 60mmHg ， mPAP ＝ 52mmHg

Implantation of Stent

Implantation of Stent

PG ＝ 5mmHg, mPAP=23mmHg

Implantation of StentExperience of Fuwai Hospital ：• 1997-2010, 29 cases ， male

23 ， female 6• 5 cases combined with VSD, 4 cases

with PDA, 1 case with SV ， 3 cases with mild aortic arch hypoplastic, 2 cases with mild AI and MI ， 2 cases after VSD repair

Implantation of Stent

• 10 cases treated by PTA with single or double balloon ， 3 cases treated by PTA and bare stent implantation ， 16 cases treat by covered CP stent implantation

• Technique successful rate: 100 ％• No major complications; no death• Results ： PG<20mmHg in 24, 20-30mmHg in 4,

>30mmHg in 1• Follow-up ： 1 case with aortic arch hypoplastic

after PTA 3 year, then implanted with stent and treated by surgery because of hypertension

Implantation of Stent

Summary• In adult-sized adolescents and adult

patients, stent placement is the treatment of choice for native and recurrent CoA

• In children ≥ 35 kg, stent placement is likely the treatment of choice for native and recurrent CoA

Thanks!