CCI: Aortic coarctation stenting achieves success, more data needed
Stent implantation for aortic coarctation achieved intermediate procedural success of 86 percent and a long-term success rate of 77 percent, but researchers said that future studies are still needed to confirm these data, according to a study published in the October issue of Catheterization and Cardiovascular Interventions.
Aortic coarctation represents 5 to 10 percent of all congenital heart disease cases, yet little data exist outlining the incidence of recurrent obstruction, aortic wall complications or blood pressure recordings.
To bulk up on these data, Ralf Holzer, MD, of Nationwide Children’s Hospital in Columbus, Ohio, and colleagues evaluated records of 302 patients who underwent aortic stent placement between December 2000 and November 2009 at 34 centers from the the Congenital Cardiovascular Interventional Study Consortium.
A valid follow-up required a form of integrated imaging data via either CT, MRI or cardiac catheterization.
A procedural failure was classified as unplanned surgical or transcatheter repeat intervention, moderate to severe re-obstruction on imaging at follow-up, and upper/lower limb systolic blood pressures of 20 mm Hg or more for nonstaged procedures or staged procedure after first repeat intervention.
Researchers found an acute procedural success rate of 96 percent, intermediate (three to 18 months) of 86 percent and long term (18 to 60 months) of 77 percent.
Four percent of patients required unplanned repeat interventions and 1 percent had aortic wall complications (2 percent intermediately and none at long-term follow-up). Other adverse events (15) occurred mainly acutely and included technical complications such as nine stent malpositions, as well as femoral artery injury and pulse loss or balloon rupture.
At long-term follow-up, 23 percent of patients continued to have systolic blood pressure above the 95th percentile, 9 percent had an upper-to-lower limb blood pressure gradient in excess of 20 mm Hg, and 32 percent were taking antihypertensive medication.
Of the 135 patients who had recurrent coarctation, 64 percent had isolated previous surgical repair of coarctation. Of the remaining patients, 15 had a prior transcatheter balloon angioplasty, 22 had a stent placement and 11 had a combination of treatments.
In 22 percent of patients, cardiac output control was used to facilitate stent placement—61 used rapid right ventricular pacing and four used rapid right atrial pacing.
Wire positioning in the ascending aorta took place in 135 of the 254 procedures where information on wire position was available. The rest of the 254 procedures were positioned in the right subclavian artery (31 percent), left subclavian artery (13 percent) and carotid arteries (2 percent).
The results showed that the median ratio of smallest coarctation diameter to diameter of the aorta at the diaphragm increased significantly from 0.44 to 0.85 after stent implantation. From pre- to post-stent implantation, the coarctation diameter improved significantly, from 6.9 mm to 13.8 mm.
The researchers found no significant differences in three invasive blood pressure gradient thresholds: less than 10 mm Hg, less than 15 mm Hg and less than 20 mm Hg with regards to procedural success at discharge, intermediate and long-term follow-up.
Of the 164 patients who underwent either early or late follow-up imaging with CT, MRI or cardiac cath, 20 percent experienced a recurrent obstruction—74 percent were mild and 26 percent moderate. Repeat interventions were electively staged procedures in 26 cases compared with 15 patient cases that were unplanned procedures.
“With a long-term procedural success of 77 percent, an incidence of aortic wall complications of 1.3 percent, and a need for unplanned reintervention of 4 percent, the results of stent implantation compare well with other surgical and interventional series,” wrote Holzer and colleagues. “However, even with successful initial stent therapy, patients continue to require long-term follow-up.
“On the basis of the data of this study, operators should aim for an immediate post-procedural gradient reduction to less than 20 mm Hg. Longer term follow-up is needed to draw further conclusions from this data,” the authors concluded.
Aortic coarctation represents 5 to 10 percent of all congenital heart disease cases, yet little data exist outlining the incidence of recurrent obstruction, aortic wall complications or blood pressure recordings.
To bulk up on these data, Ralf Holzer, MD, of Nationwide Children’s Hospital in Columbus, Ohio, and colleagues evaluated records of 302 patients who underwent aortic stent placement between December 2000 and November 2009 at 34 centers from the the Congenital Cardiovascular Interventional Study Consortium.
A valid follow-up required a form of integrated imaging data via either CT, MRI or cardiac catheterization.
A procedural failure was classified as unplanned surgical or transcatheter repeat intervention, moderate to severe re-obstruction on imaging at follow-up, and upper/lower limb systolic blood pressures of 20 mm Hg or more for nonstaged procedures or staged procedure after first repeat intervention.
Researchers found an acute procedural success rate of 96 percent, intermediate (three to 18 months) of 86 percent and long term (18 to 60 months) of 77 percent.
Four percent of patients required unplanned repeat interventions and 1 percent had aortic wall complications (2 percent intermediately and none at long-term follow-up). Other adverse events (15) occurred mainly acutely and included technical complications such as nine stent malpositions, as well as femoral artery injury and pulse loss or balloon rupture.
At long-term follow-up, 23 percent of patients continued to have systolic blood pressure above the 95th percentile, 9 percent had an upper-to-lower limb blood pressure gradient in excess of 20 mm Hg, and 32 percent were taking antihypertensive medication.
Of the 135 patients who had recurrent coarctation, 64 percent had isolated previous surgical repair of coarctation. Of the remaining patients, 15 had a prior transcatheter balloon angioplasty, 22 had a stent placement and 11 had a combination of treatments.
In 22 percent of patients, cardiac output control was used to facilitate stent placement—61 used rapid right ventricular pacing and four used rapid right atrial pacing.
Wire positioning in the ascending aorta took place in 135 of the 254 procedures where information on wire position was available. The rest of the 254 procedures were positioned in the right subclavian artery (31 percent), left subclavian artery (13 percent) and carotid arteries (2 percent).
The results showed that the median ratio of smallest coarctation diameter to diameter of the aorta at the diaphragm increased significantly from 0.44 to 0.85 after stent implantation. From pre- to post-stent implantation, the coarctation diameter improved significantly, from 6.9 mm to 13.8 mm.
The researchers found no significant differences in three invasive blood pressure gradient thresholds: less than 10 mm Hg, less than 15 mm Hg and less than 20 mm Hg with regards to procedural success at discharge, intermediate and long-term follow-up.
Of the 164 patients who underwent either early or late follow-up imaging with CT, MRI or cardiac cath, 20 percent experienced a recurrent obstruction—74 percent were mild and 26 percent moderate. Repeat interventions were electively staged procedures in 26 cases compared with 15 patient cases that were unplanned procedures.
“With a long-term procedural success of 77 percent, an incidence of aortic wall complications of 1.3 percent, and a need for unplanned reintervention of 4 percent, the results of stent implantation compare well with other surgical and interventional series,” wrote Holzer and colleagues. “However, even with successful initial stent therapy, patients continue to require long-term follow-up.
“On the basis of the data of this study, operators should aim for an immediate post-procedural gradient reduction to less than 20 mm Hg. Longer term follow-up is needed to draw further conclusions from this data,” the authors concluded.