Intervention of Aortic Coarctation: from Angioplasty to Stent Gejun Zhang, Zhongying Xu, Shiliang Jiang Cardiovascular Institute & Fuwai Hospital CAMS &PUMC, Beijing

Prevalence Western: 7-14% in CHD Chinese: 0.6-1.6% in CHD Gender: male: female2.1：1(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 angioplasty SPG: 45mmHg15mmHg

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: Balloon Guide wire：supper stiff (260cm) 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 Stent Approach 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 Stent CoA +PDA（female，45 yrs），PG＝60mmHg，mPAP＝52mmHg

Implantation of Stent

Implantation of Stent PG＝5mmHg, mPAP=23mmHg

Implantation of Stent Experience 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

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