CC BY 4.0 · Aorta (Stamford) 2015; 03(04): 136-139
DOI: 10.12945/j.aorta.2015.14.049
State-of-the-Art Review
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Most Coarctations, Recoarctations, and Coarctation-Related Aneurysms Should Be Treated Endovascularly

Edgar Luis Galiñanes
1   Department of Cardiovascular Surgery, Texas Heart Institute, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Houston, Texas, USA
,
Zvonimir Krajcer
2   Department of Cardiology, Texas Heart Institute, Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
› Author Affiliations
Further Information

Corresponding Author

Zvonimir Krajcer, MD
Department of Cardiology, Texas Heart Institute, Baylor College of Medicine
Houston, Texas 77030
USA   
Phone: +1 713 790 9401   
Fax: +1 713 790 0353   

Publication History

07 August 2014

24 July 2015

Publication Date:
24 September 2018 (online)

 

Abstract

Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA)

For patients with coarctation of the aorta (CoA), surgical intervention results in an overall survival rate nearly twice that of medical management. Therefore, surgical correction of CoA has traditionally been warranted in the majority of patients, even though open repair entails its own complications. With the advent of endovascular technology, many interventionalists hoped that this approach would decrease the complications associated with open surgical repair of CoA. Nevertheless, there is still an ongoing debate about the merits of traditional open surgery versus endovascular therapy. In this review, we discuss the role of these two approaches for the management of CoA, recoarctation, and coarctation-related aneurysms.


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Introduction

Coarctation of the aorta (CoA) has a wide spectrum of manifestations. The disease may be diagnosed at an early age in patients with acyanotic heart disease or may be diagnosed incidentally in adults. Because of this variability in presentation, each clinical scenario involving CoA is unique, and definitive management should be tailored individually for each patient. We propose that most CoAs, recoarctations, and CoA-related aneurysms are best treated with endovascular techniques and that surgery should be reserved for selected cases.


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Open Repair versus Endovascular Surgery

Traditional open repair of CoA relies on variable techniques, including direct end-to-end repair, aortoplasty, patch repair, and interposition-graft repair. All of these operations entail the cardiovascular and respiratory risks posed by general anesthesia in addition to procedural and periprocedural complications. Many procedural complications are associated with the need for cardiopulmonary bypass and aortic cross-clamping. In addition, open repair often necessitates a median sternotomy or lateral thoracotomy incision, which can result in significant morbidity. Postoperatively, patients often have a prolonged recovery, with average hospital stays lasting longer than 1 week, and need physical rehabilitation. The increased morbidity and prolonged recovery usually result in greater hospital expenses.

After performing resection with extended end-to-end anastomosis for CoA in 201 patients from 1991 through 2007, Kaushal and colleagues[1], of the Children's Memorial Hospital, in Chicago, reported an early mortality rate of 2%, in addition to the following morbidity rates: septicemia, 4%; recurrent laryngeal nerve paresis, 3%; chylothorax, 3%; pulmonary hypertensive crisis, 1%; and reoperation for ventral-septal-defect closure, mediastinitis, or delayed sternal closure, 2%. Brown and associates[2], of the Mayo Clinic, reported an overall 2.4% mortality rate for 819 patients with isolated CoA who underwent primary operative repair between 1946 and 2005 by means of extended end-to-end anastomosis, patch angioplasty, interposition grafting, bypass grafting, or subclavian flap or “other” repair. Moreover, Preventza and coauthors[3], of the Texas Heart Institute, reported a 1.9% 30-day mortality rate with re-operative surgery in 53 patients with CoA-related aneurysms. In addition, these surgeons reported the following complications: vocal-cord paralysis, 20.8%; need for prolonged mechanical ventilation, 11.3%; reoperation for bleeding, 7.5%; neurologic events, 5.7%; acute renal failure, 5.7%; and need for a tracheostomy, 3.8%.

In the Quebec Native Coarctation of the Aorta Study[4], investigators retrospectively compared surgical repair to transcatheter intervention (angioplasty) in 80 patients (mean age, 12 years) treated between 1998 and 2004. Procedure-related complications were far more common in the surgical group (50%) than in the angioplasty group (18%) (p = 0.005). The median hospital stay was 7 days for the surgical group and 1 day for the angioplasty group (p < 0.001). At 38 + 21 months, however, the rate of follow-up repeat intervention was higher in the angioplasty group (32%) than in the surgical group (0%) (p < 0.0001).

Proponents of open surgical repair often argue that in endovascular procedures, the short-term benefits of decreased morbidity and mortality are gained at the expense of durability and longevity, but that is not the case. Jenkins and colleagues[5] reported that most patients who undergo open repair are symptom-free for approximately 20 years after their initial operation, but 30% to 75% of these patients later have recurrent hypertension.

The direct end-to-end sutured anastomosis originally described by Crafoord and Nylin[6] in 1945 has largely been abandoned due to high rates of recoarctation, and many surgeons now perform alternative variations[7]. Kaushal and associates[1] reported a 4% reintervention rate after extended end-to-end anastomosis; three of their patients needed balloon angioplasty, and five patients required reoperation. In their study, 75% of reinterventions occurred within the first year after initial surgery. Alternatives, such as patch aortoplasty, have long been associated with high rates of aneurysmal formation (20–40%)[8]. The addition of polytetrafluoroethylene (PTFE) for aortoplasty lowered rates of aneurysmal disease but, unfortunately, increased rates of recoarctation to 25%[9].

In 2013, after analyzing surgical repairs of isolated CoAs performed in 819 patients at the Mayo Clinic over the past 60 years, Brown and colleagues[2] concluded that lifelong surveillance is mandatory after surgical repair. They reported that in comparison to age- and sex-matched populations, patients who underwent open repair had reduced long-term survival. Repair at an early age was an independent risk factor for reintervention. At 30 years’ follow-up, patients who underwent an initial repair before 1 year of age had an average reintervention rate of 31.1%, and patients who underwent an initial repair before 5 years of age had an average reintervention rate of 73.3%.

Endovascular approaches have the advantage of being performed under local anesthesia with sedation, avoiding the risks of general anesthesia. In addition, these procedures can be performed completely percutaneously, avoiding the morbidities that may accompany median sternotomy or lateral thoracotomy incisions. After endovascular treatment, patients often have shorter hospital stays, avoiding many common postsurgical complications such as urinary tract infections, pneumonia, and deep venous thrombosis.

In 2011, the American College of Cardiology's Congenital Cardiovascular Interventional Study Consortium published a report that compared surgery, stenting, and balloon angioplasty for the treatment of CoA[10]. This multicenter, observational, nonrandomized study involved 350 patients from 36 institutions. Compared with surgery, stent placement appeared to produce hemodynamically equivalent results during follow-up observation. Moreover, stenting was associated with significantly fewer complications [2.3% versus 8.1% for surgery and 9.8% for balloon angioplasty (p < 0.001)] and shorter hospital stays [2.4 days versus 6.4 days for surgery (p < 0.001)]. The reintervention rate was higher in the stent group; however, this finding was attributed to staged procedures or patient somatic growth, and all reinterventions carried a similar low risk of morbidity and mortality.

Recently, use of covered stents has been advocated for CoA, recoarctation, and CoA-related aneurysms ([Table 1])[3] [11] [12] [13] [14] [15] [16] [17] [18] [19]. In 2009, Botta and associates[11] reported their experience using thoracic stent grafts in the treatment of CoA. They reported a 100% technical success rate, a 0% mortality rate, and a 0% reintervention rate after a mean follow-up period of 44 months. The incidence of procedural complications was 14%. Five years later, Perera and coworkers[15] reported similar rates of technical success, mortality, and reinterventions; in addition, their procedural complication rate was 0%, most likely because of increased experience and advances in technology with newer lower-profile systems. Theoretically, covered stents have the advantages of reducing the extent of the intimal tear, creating a framework for neointimal growth, and allowing control of the integrity of the aortic wall. For these reasons, they should be the standard of care for managing coexistent aneurysmal disease.

Table 1.

Summary of selected series involving the use of stent grafts to treat native coarctation of the aorta (CoA), recurrent CoA, and CoA-associated aneurysms.

Year

First author

No. of patients

Mean age (y)

Stent type(s)

Stent model

Mean FU period (mo)

Morbidity rate (%)

Mortality rate (%)

Reintervention rate (%)

2006

Tzifa[19]

30

28

CS

Cheatham-Platinum

11

13

0

13

2007

Butera[13]

33

18

CS

Cheatham-Platinum

12

0

0

3

2008

Tanous[18]

22

39

CS

Cheatham-Platinum

12

4

0

13

2009

Botta[11]

11

45

CS

Talent/Valiant Medtronic

44

14.3

0

0

2010

Shennib[17]

22

40

BES, CS

Palmaz, Gore-TAG, Cook Zenith

31

0

0

4

2010

Bruckheimer[12]

25

CS

Advanta V12D

4.9

0

0

0

2012

Roselli[16]

59

38

CS, BES

Gore-TAG, Cook Zenith

56

3

0

12

2013

Preventza[3]

11

39

CS

Gore-TAG, Talent/Captivia, Medtronic

40

0

0

0

2013

Khavandi[14]

17

39

CS

Valiant Medtronic, Cook Zenith

31

23

0

0

2014

Perera[15]

13

45

CS

Gore-TAG, Valiant Medtronic

15

0

0

7

BES = balloon expandable stent; CS = covered stent; FU = follow-up.



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Conclusion

In patients with CoA, recoarctation, or a CoA-related aneurysm, open surgical repair is associated with an unnecessary risk of morbidity and mortality. In patients more than 1 year old, endovascular procedures have been shown to yield immediate outcomes similar to those of surgery, defined as hemodynamically controlled hypertension in the follow-up period[4]. Any argument regarding endovascular reintervention, however negligible, is formidable, because such reintervention is associated with the same risks of morbidity and mortality as the initial operation[11]. Furthermore, belief in the longevity of surgical repair for CoA is erroneous, as a large percentage of these repairs are plagued with recoarctation and CoA-related aneurysms[5]. Unfortunately, reoperative surgery in these patients entails increased risks of morbidity and mortality[3].

With the application of endovascular surgery to CoA, interventionalists have gained a new armamentarium for addressing this condition. Both interventions and reinterventions are associated with low risks of morbidity and mortality. As technology continues to evolve, the role of endovascular surgery will be further defined, clearly demonstrating that this approach is optimal for managing the majority of CoA and finally silencing this debate.


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Conflict of Interest

The authors have no conflicts of interest relevant to this publication.

  • References

  • 1 Kaushal S, Backer CL, Patel JN, Patel SK, Walker BL, Weigel TJ. , et al. Coarctation of the aorta: Midterm outcomes of resection with extended end-to-end anastomosis. Ann Thorac Surg 2009; 88: 1932-1938 . DOI: 10.1016/j.athoracsur.2009.08.035
  • 2 Brown ML, Burkhart HM, Connolly HM, Dearani JA, Cetta F, Li Z. , et al. Coarctation of the aorta: Lifelong surveillance is mandatory following surgical repair. J Am Coll Cardiol 2013; 62: 1020-1025 . DOI: 10.1016/j.jacc.2013.06.016
  • 3 Preventza O, Livesay JJ, Cooley DA, Krajcer Z, Cheong BY, Coselli JS. Coarctation-associated aneurysms: A localized disease or diffuse aortopathy. Ann Thorac Surg 2013; 95: 1961-1967 . DOI: 10.1016/j.athoracsur.2013.03.062
  • 4 Rodes-Cabau J, Miro J, Dancea A, Ibrahim R, Piette E, Lapierre C. , et al. Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study. Am Heart J 2007; 154: 186-192 . DOI: 10.1016/j.ahj.2007.03.046
  • 5 Jenkins NP, Ward C. Coarctation of the aorta: Natural history and outcome after surgical treatment. QJM 1999; 92: 365-371 . DOI: 10.1093/qjmed/92.7.365
  • 6 Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Cardiovasc Surg 1945; 14: 347-361 . DOI: 10.1016/0002-8703(46)90334-1
  • 7 Kappetein AP, Zwinderman AH, Bogers AJ, Rohmer J, Huysmans HA. More than thirty-five years of coarctation repair. An unexpected high relapse rate. J Thorac Cardiovasc Surg 1994; 107: 87-95 . PMID: 8283924
  • 8 Bromberg BI, Beekman RH, Rocchini AP, Snider AR, Bank ER, Heidelberger K. , et al. Aortic aneurysm after patch aortoplasty repair of coarctation: A prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989; 14: 734-741 . DOI: 10.1016/0735-1097(89)90119-8
  • 9 Walhout RJ, Lekkerkerker JC, Oron GH, Hitchcock FJ, Meijboom EJ, Bennink GB. Comparison of polytetrafluoroethylene patch aortoplasty and end-to-end anastomosis for coarctation of the aorta. J Thorac Cardiovasc Surg 2003; 126: 521-528 . DOI: 10.1016/S0022-5223(03)00030-8
  • 10 Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z. , et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: An observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2011; 58: 2664-2674 . DOI: 10.1016/j.jacc.2011.08.053
  • 11 Botta L, Russo V, Oppido G, Rosati M, Massi F, Lovato L. , et al. Role of endovascular repair in the management of late pseudo-aneurysms following open surgery for aortic coarctation. Eur J Cardiothorac Surg 2009; 36: 670-674 . DOI: 10.1016/j.ejcts.2009.04.056
  • 12 Bruckheimer E, Birk E, Santiago R, Dagan T, Esteves C, Pedra CA. Coarctation of the aorta treated with the Advanta V12 large diameter stent: Acute results. Catheter Cardiovasc Interv 2010; 75: 402-406 . DOI: 10.1002/ccd.22280
  • 13 Butera G, Piazza L, Chessa M, Negura DG, Rosti L, Abella R. , et al. Covered stents in patients with complex aortic coarctations. Am Heart J 2007; 154: 795-800 . DOI: 10.1016/j.ahj.2007.06.018
  • 14 Khavandi A, Bentham J, Marlais M, Martin RP, Morgan GJ, Parry AJ. , et al. Transcatheter and endovascular stent graft management of coarctation-related pseudoaneurysms. Heart 2013; 99: 1275-1281 . DOI: 10.1136/heartjnl-2012-303488
  • 15 Perera AH, Rudarakanchana N, Hamady M, Kashef E, Mireskandari M, Uebing A. , et al. New-generation stent grafts for endovascular management of thoracic pseudoaneurysms after aortic coarctation repair. J Vasc Surg 2014; 60: 330-336 . DOI: 10.1016/j.jvs.2014.02.050
  • 16 Roselli EE, Qureshi A, Idrees J, Lima B, Greenberg RK, Svensson LG. , et al. Open, hybrid, and endovascular treatment for aortic coarctation and postrepair aneurysm in adolescents and adults. Ann Thorac Surg 2012; 94: 751-756 . DOI: 10.1016/j.athoracsur.2012.04.033
  • 17 Shennib H, Rodriguez-Lopez J, Ramaiah V, Wheatley G, Kpodonu J, Williams J. , et al. Endovascular management of adult coarctation and its complications: Intermediate results in a cohort of 22 patients. Eur J Cardiothorac Surg 2010; 37: 322-327 . DOI: 10.1016/j.ejcts.2009.04.071
  • 18 Tanous D, Collins N, Dehghani P, Benson LN, Horlick EM. Covered stents in the management of coarctation of the aorta in the adult: Initial results and 1-year angiographic and hemodynamic follow-up. Int J Cardiol 2010; 140: 287-295 . DOI: 10.1016/j.ijcard.2008.11.085
  • 19 Tzifa A, Ewert P, Brzezinska-Rajszys G, Peters B, Zubrzycka M, Rosenthal E. , et al. Covered Cheatham-platinum stents for aortic coarctation: Early and intermediate-term results. J Am Coll Cardiol 2006; 47: 1457-1463 . DOI: 10.1016/j.jacc.2005.11.061

Corresponding Author

Zvonimir Krajcer, MD
Department of Cardiology, Texas Heart Institute, Baylor College of Medicine
Houston, Texas 77030
USA   
Phone: +1 713 790 9401   
Fax: +1 713 790 0353   

  • References

  • 1 Kaushal S, Backer CL, Patel JN, Patel SK, Walker BL, Weigel TJ. , et al. Coarctation of the aorta: Midterm outcomes of resection with extended end-to-end anastomosis. Ann Thorac Surg 2009; 88: 1932-1938 . DOI: 10.1016/j.athoracsur.2009.08.035
  • 2 Brown ML, Burkhart HM, Connolly HM, Dearani JA, Cetta F, Li Z. , et al. Coarctation of the aorta: Lifelong surveillance is mandatory following surgical repair. J Am Coll Cardiol 2013; 62: 1020-1025 . DOI: 10.1016/j.jacc.2013.06.016
  • 3 Preventza O, Livesay JJ, Cooley DA, Krajcer Z, Cheong BY, Coselli JS. Coarctation-associated aneurysms: A localized disease or diffuse aortopathy. Ann Thorac Surg 2013; 95: 1961-1967 . DOI: 10.1016/j.athoracsur.2013.03.062
  • 4 Rodes-Cabau J, Miro J, Dancea A, Ibrahim R, Piette E, Lapierre C. , et al. Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study. Am Heart J 2007; 154: 186-192 . DOI: 10.1016/j.ahj.2007.03.046
  • 5 Jenkins NP, Ward C. Coarctation of the aorta: Natural history and outcome after surgical treatment. QJM 1999; 92: 365-371 . DOI: 10.1093/qjmed/92.7.365
  • 6 Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Cardiovasc Surg 1945; 14: 347-361 . DOI: 10.1016/0002-8703(46)90334-1
  • 7 Kappetein AP, Zwinderman AH, Bogers AJ, Rohmer J, Huysmans HA. More than thirty-five years of coarctation repair. An unexpected high relapse rate. J Thorac Cardiovasc Surg 1994; 107: 87-95 . PMID: 8283924
  • 8 Bromberg BI, Beekman RH, Rocchini AP, Snider AR, Bank ER, Heidelberger K. , et al. Aortic aneurysm after patch aortoplasty repair of coarctation: A prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989; 14: 734-741 . DOI: 10.1016/0735-1097(89)90119-8
  • 9 Walhout RJ, Lekkerkerker JC, Oron GH, Hitchcock FJ, Meijboom EJ, Bennink GB. Comparison of polytetrafluoroethylene patch aortoplasty and end-to-end anastomosis for coarctation of the aorta. J Thorac Cardiovasc Surg 2003; 126: 521-528 . DOI: 10.1016/S0022-5223(03)00030-8
  • 10 Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z. , et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: An observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2011; 58: 2664-2674 . DOI: 10.1016/j.jacc.2011.08.053
  • 11 Botta L, Russo V, Oppido G, Rosati M, Massi F, Lovato L. , et al. Role of endovascular repair in the management of late pseudo-aneurysms following open surgery for aortic coarctation. Eur J Cardiothorac Surg 2009; 36: 670-674 . DOI: 10.1016/j.ejcts.2009.04.056
  • 12 Bruckheimer E, Birk E, Santiago R, Dagan T, Esteves C, Pedra CA. Coarctation of the aorta treated with the Advanta V12 large diameter stent: Acute results. Catheter Cardiovasc Interv 2010; 75: 402-406 . DOI: 10.1002/ccd.22280
  • 13 Butera G, Piazza L, Chessa M, Negura DG, Rosti L, Abella R. , et al. Covered stents in patients with complex aortic coarctations. Am Heart J 2007; 154: 795-800 . DOI: 10.1016/j.ahj.2007.06.018
  • 14 Khavandi A, Bentham J, Marlais M, Martin RP, Morgan GJ, Parry AJ. , et al. Transcatheter and endovascular stent graft management of coarctation-related pseudoaneurysms. Heart 2013; 99: 1275-1281 . DOI: 10.1136/heartjnl-2012-303488
  • 15 Perera AH, Rudarakanchana N, Hamady M, Kashef E, Mireskandari M, Uebing A. , et al. New-generation stent grafts for endovascular management of thoracic pseudoaneurysms after aortic coarctation repair. J Vasc Surg 2014; 60: 330-336 . DOI: 10.1016/j.jvs.2014.02.050
  • 16 Roselli EE, Qureshi A, Idrees J, Lima B, Greenberg RK, Svensson LG. , et al. Open, hybrid, and endovascular treatment for aortic coarctation and postrepair aneurysm in adolescents and adults. Ann Thorac Surg 2012; 94: 751-756 . DOI: 10.1016/j.athoracsur.2012.04.033
  • 17 Shennib H, Rodriguez-Lopez J, Ramaiah V, Wheatley G, Kpodonu J, Williams J. , et al. Endovascular management of adult coarctation and its complications: Intermediate results in a cohort of 22 patients. Eur J Cardiothorac Surg 2010; 37: 322-327 . DOI: 10.1016/j.ejcts.2009.04.071
  • 18 Tanous D, Collins N, Dehghani P, Benson LN, Horlick EM. Covered stents in the management of coarctation of the aorta in the adult: Initial results and 1-year angiographic and hemodynamic follow-up. Int J Cardiol 2010; 140: 287-295 . DOI: 10.1016/j.ijcard.2008.11.085
  • 19 Tzifa A, Ewert P, Brzezinska-Rajszys G, Peters B, Zubrzycka M, Rosenthal E. , et al. Covered Cheatham-platinum stents for aortic coarctation: Early and intermediate-term results. J Am Coll Cardiol 2006; 47: 1457-1463 . DOI: 10.1016/j.jacc.2005.11.061