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

2. Prevalence Western: 7-14% in CHD Chinese: 0.6-1.6% in CHD
Gender: male: female2.1：1(Chinese)

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

4. Pathology
From Y. Ho

5. Pathology

6. 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

7. Diagnostic Imaging X-ray plain film Echocardiography CT MRI
Angiography

8. X-ray Plain Film

9. Echocardiography

10. MDCT

11. 3D Reconstruction of MDCT

12. MRA

13. 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

14. 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

15. 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％

16. 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

17. Balloon Angioplasty
Children, male, 4yr and 6month, PG＝70mmHg

18. Balloon Angioplasty
扩张后PG＝28mmHg

19. Balloon Angioplasty SV, hybrid therapy,
Glenn shunt+CoA balloon angioplasty
SPG: 45mmHg15mmHg

20. 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

21. 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 …

22. Bare Stent for CoA

23. Covered CP Stent and BIB Catheter

24. 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

25. Implantation of Stent
male，19yrs，PG＝80mmHg

26. Implantation of Stent

27. Implantation of Stent

28. Implantation of Stent
PG=13mmHg

29. Implantation of Stent
CoA +PDA（female，45 yrs），PG＝60mmHg，mPAP＝52mmHg

30. Implantation of Stent

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

32. Implantation of Stent Experience of Fuwai Hospital：
, 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

33. 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

34. 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

35. Thanks!