Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults

Abstract

More information is needed to clarify whether stenting is superior to balloon angioplasty (BA) for unoperated coarctation of the aorta (CoA). From September 1997, 21 consecutive adolescents and adults (24 +/- 11 years) with discrete CoA underwent stenting (G1). The results were compared to those achieved by BA performed in historical group of 15 patients (18 +/- 10 years; P = 0.103; G2). After the procedure, systolic gradient reduction was higher (99% +/- 2% vs. 87% +/- 17%; P = 0.015), residual gradients lower (0.4 +/- 1.4 vs. 5.9 +/- 7.9 mm Hg; P = 0.019), gain at the CoA site higher (333% +/- 172% vs. 190% +/- 104%; P = 0.007), and CoA diameter larger (16.9 +/- 2.9 vs. 12.9 +/- 3.2 mm; P < 0.001) in G1. Aortic wall abnormalities were found in eight patients in G2 (53%) and in one in G1 (7%; P < 0.001). There was no major complication. Repeat catheterization (n = 33) and/or MRI (n = 2) was performed at a median follow-up of 1.0 year for G1 and 1.5 for G2 (P = 0.005). Gradient reduction persisted in both groups, although higher late gradients were seen in G2 (median of 0 mm Hg for G1 vs. 3 for G2; P = 0.014). CoA diameter showed no late loss in G1 and a late gain in G2 with a trend to being larger in G1 (16.7 +/- 2.9 vs. 14.6 +/- 3.9 mm; P = 0.075). Two patients required late stenting due to aneurysm formation or stent fracture in G1. Aortic wall abnormalities did not progress and one patient required redilation in G2. Blood pressure was similar in both groups at follow-up (126 +/- 12/81 +/- 11 for G1 vs. 120 +/- 15/80 +/- 10 mm Hg for G2; P = 0.149 and 0.975, respectively). Although satisfactory and similar clinical outcomes were observed with both techniques, stenting was a better means to relieve the stenosis and minimize the risk of developing immediate aortic wall abnormalities.

Balloon Dilatation and Stenting for Aortic Coarctation

“…For the primary analysis, we identified 15 stenting studies or study arms with 423 participants, 12 balloon dilatation studies or study arms with 361 participants, 2 studies comparing the 2 interventions, 30,31 and 1 study comparing stenting with surgery 32 ( Figure 2A; full list of included studies is provided in the Data Supplement). Mean follow-up time ranged from 1 to 12 years in balloon dilatation studies and from 10 months to 4.7 years in stenting studies.…”

“…For variables that were statistically significantly different between groups, and other variables that were considered to have a systematic effect on outcomes, we constructed forest plots to examine any potential effect on 4 key outcomes: proportion of patients achieving a gradient reduction ≤20 mm Hg; proportion achieving a gradient reduction ≤10 mm Hg; 30-day mortality; proportion of patients with severe complications before discharge. An example is Figure 3,30,31,[34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50] which demonstrates that for both interventions, average pretreatment blood pressure gradient ( Figure 3A) and proportion of patients with native coarctation ( Figure 3B) do not systematically influence the proportion of patients with successful treatment. Further exploration of the effect of patient baseline characteristics on key outcomes is provided in Figures SI-SXII in the Data Supplement).…”

“…31 Accordingly, a lower number of reinterventions for recurrent coarctation could be expected. Contradicting this theoretical advantage, we found no statistically significant difference in the proportion of patients with reinterventions at follow-up.…”

Magnetic Resonance Imaging–Guided Balloon Angioplasty of Coarctation of the Aorta

“…It is the basis for making the decision whether PTA, stent placement, or surgery should be performed and allows potential complications such as vessel-wall abnormalities to be assessed. [1][2][3]17 Several studies have reported evaluation of the function and anatomy of CoA using velocity-encoded cine MRI and contrast-enhanced magnetic resonance angiography. 15,31 Assessment of pressure gradients across a vascular stenosis is limited when velocity-encoded cine MRI is used because of spin dephasing, which accompanies turbulent blood flow.…”

“…Depending on the morphology of the stenosis, its hemodynamic severity, the age of the patient, and other associated cardiovascular malformations, CoA may be treated by percutaneous transluminal balloon angioplasty (PTA), endovascular stent placement, or surgery. [1][2][3] However, restenosis or aneurysm formation can occur after interventional or surgical treatment. 4 -6 Therefore, patients need careful follow-up with repeated cardiac catheterization sessions to evaluate the hemodynamic severity of the stenosis and optionally to reintervene if this is indicated and possible.…”