Periprocedural and short-term outcomes of stenting of coarctation of the aorta in adults: A retrospective analysis from a series of seven cases

Sudarshan Kumar Vijay; Ashish Jha; Bhuwan Chandra Tiwari; Amresh Kumar Singh; Naveen Jamwal

doi:10.4103/heartindia.heartindia_47_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 3 | Page : 134-139

Periprocedural and short-term outcomes of stenting of coarctation of the aorta in adults: A retrospective analysis from a series of seven cases

Sudarshan Kumar Vijay, Ashish Jha, Bhuwan Chandra Tiwari, Amresh Kumar Singh, Naveen Jamwal
Department of Cardiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission	30-Sep-2022
Date of Acceptance	27-Oct-2022
Date of Web Publication	14-Dec-2022

Correspondence Address:
Sudarshan Kumar Vijay
Department of Cardiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/heartindia.heartindia_47_22

Abstract

Background: Coarctation of the aorta (CoA) is a rare congenital heart disease for which ballooning or surgery is recommended in the early stages of life, however, in adult patients, stenting has emerged as the treatment of choice. Data on various techniques and outcomes of stenting in CoA in Indian patients are scarcely available.
Materials and Methods: Seven adult patients of CoA treated at our center with stenting between the years 2018 and 2022 were retrospectively studied. All patients were analyzed for their clinical presentation, coarctation segment anatomy, use of various techniques for stent deployment, perioprocedural outcomes, and 3-month echocardiography (ECHO)-based follow-up with the study of gradients and clinical features. The use of various hardware to facilitate stenting was studied, and predictors of successful stenting were also defined in the analysis.
Results: The mean age of the coarctation patients was 19.1 ± 3.7 years with a male-to-female ratio of 3:4. The mean systolic blood pressure at baseline was 162.5 ± 12.6 mm of Hg and mean diastolic blood pressure of 95.7 ± 5.3 mm of Hg. The mean peak systolic gradient across the coarctation segment at baseline was 46 ± 8.2 mm of Hg. Combined antegrade and retrograde access was used for stenting of CoA in four patients (57%). Good-sized isthmus was present in only three patients (42%), and balloon predilatation was required in three patients (42%). The use of combined antegrade and retrograde route, good-sized isthmus, and adequate balloon predilatation were predictors of successful wire crossing and stent deployment across the coarctation segment. The mean ECHO-based follow-up gradient at 3 months was 9.2 ± 2.5 mm of Hg.
Conclusions: Stenting for native CoA with the use of Cheatham-platinum stents in adult patients is a highly effective and safe therapy. Longer-term follow-up studies are required to show the exact incidence of stent fracture and aneurysm formation after stenting.

Keywords: Adults, coarctation, stenting

How to cite this article:
Vijay SK, Jha A, Tiwari BC, Singh AK, Jamwal N. Periprocedural and short-term outcomes of stenting of coarctation of the aorta in adults: A retrospective analysis from a series of seven cases. Heart India 2022;10:134-9

How to cite this URL:
Vijay SK, Jha A, Tiwari BC, Singh AK, Jamwal N. Periprocedural and short-term outcomes of stenting of coarctation of the aorta in adults: A retrospective analysis from a series of seven cases. Heart India [serial online] 2022 [cited 2023 Feb 3];10:134-9. Available from: https://www.heartindia.net/text.asp?2022/10/3/134/363545

Introduction

Coarctation of the aorta (CoA) is a congenital cardiac malformation responsible for approximately 4–7% of congenital heart disease cases.^[1] It presents usually as an isolated discrete narrowing of the descending thoracic aorta just distal to the left subclavian artery with normal to varying degrees of arch hypoplasia or may be seen in association with other congenital cardiac defects such as bicuspid aortic valve, subaortic stenosis, ventricular and atrial septal defects, and mitral valve abnormalities.^[2] It usually presents in infancy or early childhood, but many cases may remain undetected until late childhood or adulthood.^[3] The usual presentation in adults is with hypertension, however, some may present with leg fatigue, claudication, or abdominal angina.^[4] Transcatheter therapy of aortic coarctation was first introduced in the form of balloon angioplasty of recurrent coarctation after surgical treatment, but it had many drawbacks such as recoarctation and aortic wall trauma leading to dissection or aneurysm formation.^[5] To overcome some of these limitations of balloon angioplasty of coarctation, balloon-expandable bare metal stents emerged as new therapeutic options.^[6]

Over the last one decade, intravascular stent therapy has become the first modality of treatment for uncomplicated adult or late childhood coarctation.^[7],[8],[9] Since the first use of a stainless steel wire containing luminal graft in 1980s by Palmaz et al.,^[10] many refinements have been made in intravascular stent technology in terms of improved profile, more flexibility, open cell design, better radial strength, and nontraumatic edges, with the option of covered stent.^[11] The commonly used stents for treating CoA include the Palmaz stent (Cordis Corp, NJ, USA), Genesis XD (Cordis Corp., NJ, USA), the ev3 Maxi (ev3, Plymouth, MN, USA), and the Cheatham-platinum (CP)^[12] bare metal or covered stent^[13] (NuMed Corp., NJ, USA). The characteristics of an ideal stent for treating coarctation include limited forshortening, good radial strength, fracture-resistant, and dilatable up to 12–22 mm sizes.

Study design and methods

Seven patients of CoA, who presented in late childhood or as adults at our center and were treated with stenting between the period of 2018 and 2022 year were retrospectively studied from their case records, echocardiographic records, angiographic catheterization laboratory digital records, and follow-up charts.

The clinical mode of presentation of patients with age, sex, and other characteristics was studied. The presence of associated cardiac and noncardiac anomalies was identified. Baseline, immediate postprocedural, and follow-up blood pressures were analyzed. Echocardiographic baseline, postprocedural, and short-term (3 months) follow-up gradients were retrospectively studied. Angiographic anatomy of the coarctation segment, technical considerations of coarctation site crossing, balloon predilatation, type and size of intravascular stent, mounting balloon and other hardware, use of retrograde alone or combined antegrade–retrograde technique, pre- and postcatheterization gradients, and the presence of absence of complication during the procedure were analyzed using digital catheterization laboratory records and cine films. Access site closure and complications were also studied. The numerical and percentage values are presented as mean ± standard deviation. The predictors of successful coarctation crossing and stent deployment were also analyzed from the case series.

Results

The mean age of the patients was 19.1 ± 3.7 years with the youngest being 15 years old and the eldest being 26 years of age. The male-to-female ratio in our case series was 3:4 [Table 1]. The most common mode of presentation in all patients was uncontrolled upper extremity hypertension with a mean systolic blood pressure of 162.5 ± 12.6 mm of Hg and mean diastolic blood pressure of 95.7 ± 5.3 mm of Hg. Two patients had additional symptoms of lower limb fatigue and claudication. One female patient also had a history of mid-trimester abortion. In six patients, there was isolated cardiac involvement and one female patient had associated systemic involvement in the form of other syndromal phenotypical (high-arched palate, cleft lip, and vaginal agenesis) features. Four patients had an appreciable systolic murmur in the back and one patient had a continuous murmur of collaterals. Four patients had the presence of classical notching of ribs on chest X-ray. Five patients presented with CoA as an isolated cardiac anomaly and two patients also had associated bicuspid aortic valve without significant stenosis or regurgitation. The mean peak systolic gradient across the coarctation segment was 46 ± 8.2 mm of Hg by Doppler echocardiography (ECHO). All patients had evidence of left ventricular hypertrophy by 12-channel electrocardiogram and M-mode ECHO.

Table 1: Clinical, demographic, and anatomical characteristics of coarctation patients

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Combined antegrade and retrograde access was used for stenting of CoA in four patients (57%) to facilitate wire crossing [Table 2]. Good-sized isthmus was present in only three patients (42%), in which direct retrograde wire crossing was done successfully. BIB (balloon in balloon) (NuMed Corp., NJ, USA) balloon was used for stent deployment in six patients, and in one patient, the stent was deployed over Z-MED II balloon (NuMed Corp., NJ, USA). Bare metal CP (NuMed Corp., NJ, USA) stent was used in six patients and one patient required the use of covered CP stent because of an associated aneurysm. The most commonly used size of CP stent was 8-Zig, 39 mm stent for discrete coarctations. One patient had a complete interruption of the aorta in whom coronary chronic total occlusion (CTO) hardware was used to cross the interrupted segment and prepare the bed for stent delivery. Another patient with very severe coarctation required the use of coronary guidewire for crossing the coarctation segment. Balloon predilatation was required in three patients (42%). Long sheath through a coarctation segment was used for stent delivery in only one patient, and all other patients underwent stent implantation through 40-cm sheath. Complication in the form of stent dislodgment occurred in one patient, in whom direct stent crossing was tried in a severe coarctation segment. Stent was dislodged over the stiff wire, which after predilatation through the antegrade route was recaptured on BIB balloon partially from the retrograde route and pushed across the lesion, and deployed successfully. Rapid transvenous pacing was used for CP stent deployment in three patients. Use of combined antegrade and retrograde route, good-sized isthmus, and adequate balloon predilatation were predictors of successful wire crossing and stent deployment across the coarctation segment [Figure 8]. Angiographic anatomy and postprocedural results of all patients are depicted in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]. All patients underwent 3-month follow-up at which mean systolic blood pressure was 136.4 ± 8.4 mm of Hg and mean diastolic blood pressure was 83.7 ± 5.2 mm of Hg. The mean peak systolic gradient by Doppler ECHO at 3-month follow-up was 9.2 ± 2.5 mm of Hg.

Table 2: Technical considerations and periprocedural characteristics of coarctation patients

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Figure 1: Discrete coarctation in a 16-year-old female (a), CP stent deployment on 14 mm BIB balloon (b), Final angiographic result (c). CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 2: Discrete coarctation in a 18-year-old male (a), CP stent deployed on 20 mm BIB balloon with final angiographic result (b). CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 3: Interrupted aortic arch in 15-year-old female (a), use of coronary CTO guidewire for crossing (b), CP stent deployed over 14 mm Z-med II balloon (c), Final angiographic result (d). CTO: coronary chronic total occlusion, CP: Cheatham-platinum

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Figure 4: Discrete coarctation in a 22-year-old female (a), CP stent deployment on 16 mm BIB balloon (b), Final angiographic result (c). CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 5: Severe discrete coarctation in a 22-year-old female (a), Direct CP stent crossing resulted in stent dislodgment (b), CP Stent pushed across lesion over 14 mm BIB balloon after antegrade balloon dilatation (c), final angiographic result (d). CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 6: Discrete coarctation in a 16-year-old male (a), CP stent deployed over 16 mm BIB balloon with final angiographic resul (b), t. CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 7: Discrete coarctation in a 21-year-old male with aneurysm (a), Covered CP stent over 16 mm BIB balloon deployed over long sheath (b), Final angiographic result (c). CP: Cheatham-platinum, BIB: Balloon in balloon

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Figure 8: Three important factors of successful wire crossing and stent delivery across coarctation segment and their use in percentage in our series

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Discussion

Stenting for CoA in adults has gained widespread acceptance as the preferred therapy and the results of many studies also support its use as compared to surgical therapy.^[14] The balloon-in-balloon is by far the preferred delivery balloon when initial stent expansion is ≥18 mm as it facilitates controlled stent expansion, the ability to adjust stent position following inner balloon expansion, and decreased the incidence of stent foreshortening. For those stents which are initially deployed on ≤16 mm balloon catheters, the Z-Med II^TM balloon catheters (NuMed inc., NY, USA) are the most commonly used.^[14] CP stent is one of the most commonly used stents for coarctation, which is available both as bare metal or covered graft stent.^[15] In our series, CP stent was used in all cases and one patient required the use of covered CP stent, with successful deployment in all patients. In one study, a direct comparison of covered and bare metal CP stents was done with intermediate-term follow-up^[16] in patients with severe CoA and showed that rates of recoarctation and pseudoaneurysm formation in two types of stents were not statistically different at 31 months of follow-up. High-risk coarctation is defined as CoA in >40 years of age, in Turner syndrome and those with near atresia of aorta, in these situations, use of covered CP stent may be preferred.^[17],[18]

In our series, the use of combined antegrade and retrograde routes was an important predictor of the success of wire crossing in very severe or nearly atretic CoA. Use of coronary hardwares can increase the chances of coarctation segment crossing in total atresia or near-total occlusion, followed by graded balloon dilatation. Balloon predilatation using smaller balloons can be used to facilitate stent delivery; however, aggressive larger-size balloon predilatation should be avoided to mitigate the chances of aneurysm formation on long-term follow-up due to vessel wall injury. One systematic review^[19] in stenting for CoA showed that periprocedural complications are limited, with stent migration being the most common (2.4%). Death was uncommon (0.4%), despite the occurrence of aortic dissection (0.9%) and rupture (0.4%). In our series, one patient had stent dislodgement which was successfully retrieved over BIB balloon and deployed with good end results. Another systematic review and meta-analysis have shown that stenting can be the preferred method of treatment of native coarctation even in younger patients.^[20]

Late stent fracture or aneurysm formation is a concern for bare metal stents. Lack of intermediate-term and long-term angiographic-based follow-up was a drawback of our series, however, very few studies have reported long-term follow-up beyond 5 years which showed independent predictors for stent fractures at late follow-up were age >18 years, minimum stent diameter ≥12 mm, and male sex^[21] and cumulative incidence of aneurysm formation at late follow-up was 6.3%.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

Proper ethical approval was received from the institutional ethics committee.

Authors' contributions

Sudarshan Kumar Vijay(SKV), Ashish Jha(AJ) , Bhuwan Chandra Tiwari(BCT), Amresh Kumar Singh(AKS) and Naveen Jamwal (NJ) contributed to patient management and data collection. SKV drafted the manuscript.

References

1.	Golden AB, Hellenbrand WE. Coarctation of the aorta: Stenting in children and adults. Catheter Cardiovasc Interv 2007;69:289-99.
2.	Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-900.
3.	Ringel RE, Gauvreau K, Moses H, Jenkins KJ. Coarctation of the aorta stent trial (COAST): Study design and rationale. Am Heart J 2012;164:7-13.
4.	Liberthson RR, Pennington DG, Jacobs ML, Daggett WM. Coarctation of the aorta: Review of 234 patients and clarification of management problems. Am J Cardiol 1979;43:835-40.
5.	Rao PS, Galal O, Smith PA, Wilson AD. Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol 1996;27:462-70.
6.	O'Laughlin MP, Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation 1991;83:1923-39.
7.	Ebeid MR, Prieto LR, Latson LA. Use of balloon-expandable stents for coarctation of the aorta: Initial results and intermediate-term follow-up. J Am Coll Cardiol 1997;30:1847-52.
8.	Forbes TJ, Moore P, Pedra CA, Zahn EM, Nykanen D, Amin Z, et al. Intermediate follow-up following intravascular stenting for treatment of coarctation of the aorta. Catheter Cardiovasc Interv 2007;70:569-77.
9.	Qureshi AM, McElhinney DB, Lock JE, Landzberg MJ, Lang P, Marshall AC. Acute and intermediate outcomes, and evaluation of injury to the aortic wall, as based on 15 years experience of implanting stents to treat aortic coarctation. Cardiol Young 2007;17:307-18.
10.	Palmaz JC, Sibbitt RR, Reuter SR, Garcia F, Tio FO. Expandable intrahepatic portacaval shunt stents: Early experience in the dog. AJR Am J Roentgenol 1985;145:821-5.
11.	Holzer RJ, Chisolm JL, Hill SL, Cheatham JP. Stenting complex aortic arch obstructions. Catheter Cardiovasc Interv 2008;71:375-82.
12.	Meadows J, Minahan M, McElhinney DB, McEnaney K, Ringel R, COAST Investigators*. Intermediate outcomes in the prospective, multicenter Coarctation of the Aorta Stent Trial (COAST). Circulation 2015;131:1656-64.
13.	Taggart NW, Minahan M, Cabalka AK, Cetta F, Usmani K, Ringel RE, et al. Immediate Outcomes of covered stent placement for treatment or prevention of aortic wall injury associated with coarctation of the aorta (COAST II). JACC Cardiovasc Interv 2016;9:484-93.
14.	Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z, et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: An observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2011;58:2664-74.
15.	Tzifa A, Ewert P, Brzezinska-Rajszys G, Peters B, Zubrzycka M, Rosenthal E, et al. Covered cheatham-platinum stents for aortic coarctation: Early and intermediate-term results. J Am Coll Cardiol 2006;47:1457-63.
16.	Sohrabi B, Jamshidi P, Yaghoubi A, Habibzadeh A, Hashemi-Aghdam Y, Moin A, et al. Comparison between covered and bare cheatham-platinum stents for endovascular treatment of patients with native post-ductal aortic coarctation: Immediate and intermediate-term results. JACC Cardiovasc Interv 2014;7:416-23.
17.	Kenny D, Margey R, Turner MS, Tometzki AJ, Walsh KP, Martin RP. Self-expanding and balloon expandable covered stents in the treatment of aortic coarctation with or without aneurysm formation. Catheter Cardiovasc Interv 2008;72:65-71.
18.	Forbes TJ, Garekar S, Amin Z, Zahn EM, Nykanen D, Moore P, et al. Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: A multi-institutional study. Catheter Cardiovasc Interv 2007;70:276-85.
19.	Hartman EM, Groenendijk IM, Heuvelman HM, Roos-Hesselink JW, Takkenberg JJ, Witsenburg M. The effectiveness of stenting of coarctation of the aorta: A systematic review. EuroIntervention 2015;11:660-8.
20.	Yang L, Chua X, Rajgor DD, Tai BC, Quek SC. A systematic review and meta-analysis of outcomes of transcatheter stent implantation for the primary treatment of native coarctation. Int J Cardiol 2016;223:1025-34.
21.	Holzer RJ, Gauvreau K, McEnaney K, Watanabe H, Ringel R. Long-term outcomes of the coarctation of the aorta stent trials. Circ Cardiovasc Interv 2021;14:e010308.