Balloon Dilatation and Stenting for Aortic Coarctation

Abstract

Background— There is no systematic assessment of available evidence on effectiveness and comparative effectiveness of balloon dilatation and stenting for aortic coarctation. Methods and Results— We systematically searched 4 online databases to identify and select relevant studies of balloon dilatation and stenting for aortic coarctation based on a priori criteria (PROSPERO 2014:CRD42014014418). We quantitatively synthesized results for each intervention from single-arm studies and obtained pooled estimates for relative effectiveness from pairwise and network meta-analysis of comparative studies. Our primary analysis included 15 stenting (423 participants) and 12 balloon dilatation studies (361 participants), including patients ≥10 years of age. Post-treatment blood pressure gradient reduction to ≤20 and ≤10 mm Hg was achieved in 89.5% (95% confidence interval, 83.7–95.3) and 66.5% (44.1–88.9%) of patients undergoing balloon dilatation, and in 99.5% (97.5–100.0%) and 93.8% (88.5–99.1%) of patients undergoing stenting, respectively. Odds of achieving ≤20 mm Hg were lower with balloon dilatation as compared with stenting (odds ratio, 0.105 [0.010–0.886]). Thirty-day survival rates were comparable. Numerically more patients undergoing balloon dilatation experienced severe complications during admission (6.4% [2.6–10.2%]) compared with stenting (2.6% [0.5–4.7%]). This was supported by meta-analysis of head-to-head studies (odds ratio, 9.617 [2.654–34.845]) and network meta-analysis (odds ratio, 16.23, 95% credible interval: 4.27–62.77) in a secondary analysis in patients ≥1 month of age, including 57 stenting (3397 participants) and 62 balloon dilatation studies (4331 participants). Conclusions— Despite the limitations of the evidence base consisting predominantly of single-arm studies, our review indicates that stenting achieves superior immediate relief of a relevant pressure gradient compared with balloon dilatation.

Beyond Pressure Gradients: The Effects of Intervention on Heart Power in Aortic Coarctation

“…Recently, blood pressure reduction in patients after renal denervation was shown to occur as a gradual decrease that extends to at least one-year follow-up [24]. However, the problem of persisting hypertension in CoA at longer-term intervals has been demonstrated before and choosing longer follow-up periods in the assessment of heart power carries the risk of bias from re-stenosis, especially after balloon angioplasty [10, 25]. …”

Avoidable costs of stenting for aortic coarctation in the United Kingdom: an economic model

“…Estimates of event probabilities were derived primarily from a meta-analysis comparing the effectiveness of stenting and balloon dilatation in CoA patients [9]. For event probabilities at different follow-up periods, we used pooled estimates for aortic wall injuries after stenting; overall reintervention rates at short- and mid-term follow-up; and the proportion of patients requiring anti-hypertensive medication at short- and mid-term follow-up.…”

“…Our data were based on studies that were randomized controlled trials with a minimum of 50 participants, or other study designs with at least 50 participants and that were conducted in high income countries. Additional details are available elsewhere [9]. …”

“…Implementation of a stent is an effective option to repair the obstructed site of the aorta, yet patients are still at risk of experiencing serious complications while undergoing treatment, and outcomes at follow-up show scope for significant improvement. Recurrent CoA and aortic wall injuries contribute to a reintervention rate after stenting of approximately 14% at follow-up [9]. …”

The Adult with Coarctation of the Aorta

“…According to guidelines, the first line medications in the treatment of hypertension in patients with CoA are angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARB), and beta blockers (BB) [50]. Hypertension can be treated with medical management, but coarctation or recoarctation of the aorta need to be repaired either percutaneously or surgically [47,63]. Choosing one intervention over another depends on the individual patient and should be done in collaboration with an interdisciplinary team including an adult congenital heart disease (ACHD) cardiologist, interventionalist and surgeon with training in ACHD.…”