Stent Angioplasty for Critical Native Aortic Coarctation in Three Infants: Up to 15-Year Follow-Up Without Surgical Intervention and Review of the Literature

Abstract

Management of neonatal native coarctation is debated till now. Surgical therapy remains an option but may be unwarranted in critically sick infants with complex lesions. Balloon dilatation has been employed but with early re-stenosis. Stent angioplasty has also been used but as a bridge towards definitive surgical therapy. Four critically sick infants with complex coarctation and additional co-morbidity factors underwent primary stent therapy as surgical intervention was denied. One patient had died earlier due to reasons unrelated to the procedure. Three survivors underwent multiple dilatations of primary stents as indicated. One of the three survivors did not require any further dilatation after the age of 5 years and remained stable till the time of reporting. High-pressure Cheatham Platinum stents were implanted inside the primary stents in two infants, who developed re-stenosis due to somatic growth. These stents were further balloon dilated at high atmospheric pressure. Femoral arteries in both of them were blocked but were re-canalized after balloon dilatation in one and stent angioplasty in the other. After a follow-up of about 15 years, all of them have been doing fine with acceptable Doppler gradients. They were normotensive and on no cardiac medications. It can be concluded that, though surgical repair remains a standard of care, stent angioplasty in selected infants with complex lesions is feasible and effective. Multiple dilatations can be performed without added risk of stent migration. Bio-absorbable and growth stents hold a promise for future use in such situations.

First use and limitations of Magmaris® bioresorbable stenting in a low birth weight infant with native aortic coarctation

“…Especially in sick preterm and low birth weight infants, it seems reasonable to bridge the patient until surgery can be performed at a lower risk. While interventional balloon angioplasty has been described even in very small infants, some authors have also reported successful stent usage in pre‐ and postoperative aortic coarctation in infants . Typically, coronary bare metal stents with a target diameter of 3,5–4 mm were considered.…”

“…(B) Echocardiographic evidence of significant restenosis and (C) impaired systolic left ventricular function after discontinuation of prostaglandin E1 infusion has been described even in very small infants, some authors have also reported successful stent usage in pre-and postoperative aortic coarctation in infants. 1,[7][8][9] Typically, coronary bare metal stents with a target diameter of 3,5-4 mm were considered. These stents are suitable for interventional redilation and have provided acceptable results.…”

“…However, in some patients, for example, sick preterm or low birth weight infants, surgery is associated with a much higher complication rate. Thus, there is an ongoing debate on potential alternatives to immediate surgery that bridge the patient until surgery can be performed at a lower risk . While several strategies including interventional, surgical, and hybrid approaches in low birth weight infants have been described, the theoretically appealing alternative of bioresorbable stent implantation in preterm or small for gestational age infants with native aortic coarctation has not been reported to date.…”

“…Thus, there is an ongoing debate on potential alternatives to immediate surgery that bridge the patient until surgery can be performed at a lower risk. 1 While several strategies including interventional, surgical, and hybrid approaches in low birth weight infants have been described, 2-5 the theoretically appealing alternative of bioresorbable stent implantation in preterm or small for gestational age infants with native aortic coarctation has not been reported to date. Herein, we describe the case of a 1,980 g infant with critical aortic coarctation and several other malformations, who was bridged to surgery by off-label implantation of a Magmaris ® magnesium-based bioresorbable vascular scaffold (Biotronik AG, Bülach, Switzerland 6 ).…”

Indications for stenting of coarctation of the aorta in children under 3 months of age

“…Stenting of coarctation of the aorta (CoA) is well established in adults and children weighing more than 25 kg, but even in smaller children this technique is gaining acceptance [1,2]. In smaller children aged 3 months or more, ballooning is a treatment option for native and recurrent CoA [3], but there are recent reports of even smaller patients undergoing stent therapy as either a bridge to operation or as primary treatment [4][5][6][7][8][9]. Stenting of coarctations in small children has been carried out for several reasons in a limited number of patients [4][5][6][7][8]10].…”