- Email: [email protected]
Aortic Endoprosthesis for the Treatment of Native Aortic Coarctation and Concomitant Aneurysm in an Octogenarian Patient
Accepted Manuscript Aortic Endoprosthesis for the Treatment of Native Aortic Coarctation and Concomitant Aneurysm in an Octogenarian Patient Martín Rabellino, MD, Vadim Kotowicz, MD, Alberto Kenny, Andres Alejandro Kohan, MD, Ricardo García-Mónaco, MD PII:
S0890-5096(15)00621-4
DOI:
10.1016/j.avsg.2015.06.084
Reference:
AVSG 2505
To appear in:
Annals of Vascular Surgery
Received Date: 1 May 2015 Accepted Date: 11 June 2015
Please cite this article as: Rabellino M, Kotowicz V, Kenny A, Kohan AA, García-Mónaco R, Aortic Endoprosthesis for the Treatment of Native Aortic Coarctation and Concomitant Aneurysm in an Octogenarian Patient, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.06.084. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT AORTIC ENDOPROSTHESIS FOR THE TREATMENT OF NATIVE AORTIC COARCTATION AND CONCOMITANT ANEURYSM IN AN OCTOGENARIAN
RI PT
PATIENT
Case Report
SC
Martín Rabellino MD1, Vadim Kotowicz MD2, Alberto Kenny1, Andres Alejandro
M AN U
Kohan MD1, Ricardo García-Mónaco MD1.
1. Department of Interventional Radiology. Hospital Italiano. Buenos Aires (Argentina’
TE D
2. Department of Cardiovascular Surgery. Hospital Italiano. Buenos Aires (Argentina’
Institutional affiliation:
EP
Hospital Italiano de Buenos Aires
AC C
Juan D Peron 3190 CP:C1181ACH, Buenos Aires, Argentina 5411 4959-0595
[email protected] [email protected] [email protected]
ACCEPTED MANUSCRIPT [email protected]
RI PT
[email protected]
Correspondence to:
SC
Martín Rabellino
4190, Buenos Aires, Argentina.
M AN U
Department of Radiology, Hospital Italiano de Buenos Aires, C/ Pte. J. D. Perón
Phone: 54-11-4959-0453, ext. 8347
TE D
Fax: 54-11-4959-0471 or 54-11-4959-0200
EP
E-mail: [email protected]
AC C
Short running title: Endovascular treatment of an octogenarian patient with a concomitant aortic coarctation and post-stenotic aneurysm.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
EP
AORTIC ENDOPROSTHESIS FOR THE TREATMENT OF NATIVE AORTIC
AC C
COARCTATION AND CONCOMITANT ANEURYSM IN AN OCTOGENARIAN PATIENT
ABSTRACT
We report a case of an 82-year-old female patient with native coarctation of the aorta and post-stenotic aneurysm of the descending thoracic aorta. Upon consultation she was receiving four antihypertensive drugs and physical
ACCEPTED MANUSCRIPT examination revealed non-palpable lower limb pulses with intermittent claudication at 50 m. Because of her age, high surgical risk and combination of
RI PT
lesions, endovascular treatment was suggested. Placement of a Valiant thoracic aorta endoprosthesis followed by coarctation angioplasty was performed. At 48
SC
hours, the patient was discharged on one antihypertensive drug, palpable pulses on both limbs and a normal ankle-brachial index. At one month follow-up
M AN U
the patient remained as discharged and multislice computed tomography angiography depicted complete coarctation expansion without residual stenosis,
TE D
exclusion of the aortic aneurysm, and no signs of endoleaks.
AC C
EP
Key Words: Aortic coarctation, aortic endoprosthesis, aortic aneurysm
ACCEPTED MANUSCRIPT INTRODUCTION
Coarctation of the aorta has a reported incidence between 5-8% in patients with
RI PT
congenital heart anomalies (1’. Mean age of mortality in patients that did not undergo corrective surgery is 35 years. Ninety per cent of them die before 50
SC
years of age due to systemic hypertension, coronary disease, aortic dissection,
M AN U
stroke and congestive cardiac failure (1’. Therefore, native coarctation of the aorta is very rare in adults and is generally secondary to recoarctations occurring after open or endovascular surgery (2’.
TE D
Treatment options include open and endovascular surgery. In the latter, the most common techniques are angioplasty, uncovered stent and, more recently,
EP
covered stent, which is supposed to reduce complications associated with the
AC C
other two endovascular techniques (3’. We report an 82-year-old female patient who presented with a native coarctation and concomitant aortic aneurysm, which were treated with aortic endoprosthesis. CASE REPORT
ACCEPTED MANUSCRIPT Eighty-two-year-old female patient with a history of arterial hypertension secondary to aortic coarctation diagnosed at adolescence. On a routine chest
RI PT
X-Ray ordered by her physician a widened mediastinum is seen. To further study the X-Ray findings, a multidetector computed tomography angiography
SC
(MCTA’ is ordered (Fig. 1 A-C’, revealing an aortic coractation of the descending aorta beneath the left subclavian artery, with a 5cm wide post-
M AN U
stenotic aneurysm. Due to the MCTA findings and her age, she is referred to our department for eventual treatment. Upon consultation she was currently
TE D
receiving four antihypertensive drugs, atenolol 50 mg/d, enalapril 10 mg/d, hydrochlorothiazide 25 mg/d and amlodipine 10 mg/d. Physical examination,
EP
showed no palpable pulses on her lower limbs, bilateral intermittent claudication
AC C
at 50 m and bilateral 0.4 ankle-brachial index (ABI’. Due to the complexity of both lesions, her age and the favorable anatomical characteristics of her aorta endovascular treatment is offered consisting of an aortic endoprothesis. . The procedure was done under systemic heparinization 100 U/I/k weight. Under general anesthesia she underwent right common femoral artery dissection and right brachial artery percutaneous puncture. A 5 French catheter was placed to
ACCEPTED MANUSCRIPT further insert a pig-tail catheter all the way into the ascending aorta. This allowed both a diagnostic angiography of the thoracic aorta (Fig 2A-B’, and
RI PT
angiographic control during the procedure. Through the arteriotomy, a 5 French vertebral hydrophilic catheter used to
SC
overcome the coarctation is inserted on a 0.035 hydrophilic guidewire. Pressures prior and distal to the stenosis were analyzed, and a 95 mmHg
M AN U
gradient is obtained.
A Lundequist guidewire was inserted up to the ascending aorta, on which a 10
TE D
mm angioplasty balloon was placed for dilation of the coarctation, which, as MCTA showed, had a 5 mm diameter. Afterwards, a Valiant thoracic aorta
EP
endoprosthesis (Valiant Captivia®, Medtronic’ measuring 24x24x150 mm was
AC C
inserted and used to cover both the coarctation and the aneurysm. Another angioplasty is then performed using a balloon with a 15 mm diameter (Fig 2D’. Angiographic control after the procedure depicted full expansion of the stenotic lesion, with no signs of residual stenosis, no further translesional pressure gradient, aneurysm exclusion, and no evidence of type II endoleak through the collaterals (Fig 3A-B’. The patient had a favorable recovery, with no
ACCEPTED MANUSCRIPT complications after surgery. Furthermore, 3 antihypertensive drugs were discontinued immediately after the procedure, with her blood pressure
RI PT
remaining within normal parameters. At 48 h the patient was discharged home on one antihypertensive drug and aspirin 100 mg/d. Upon physical examination
SC
both limbs had palpable pulses with an ABI of 1. The patient returned for control one week later referring no further intermittent claudication. A control MCTA
M AN U
performed one month after the procedure depicted absence of residual stenosis, exclusion and thrombosis of the aneurysmatic sac, no evidence of
DISCUSSION
TE D
leaks and no further collateral circulation (Fig 3E’.
EP
Over the last decades, there have been great advances in the surgical
AC C
treatment of aortic coarctation. From the first surgery carried out by doctors Crawford and Nylin in 1944 to date, surgical techniques have improved (4-5’, with the inclusion of the endovascular treatment as an option. The results of these types of treatments in adult patients are comparable to those offered by open surgery in patients with native aortic coarctations (6’. Despite being a great advancement, all these techniques are associated with immediate and
ACCEPTED MANUSCRIPT late complications, such as dissections, arterial ruptures, neurological complications, stent migration, pseudoaneurysms, recoarctations and death.
RI PT
Covered stent has recently emerged as an option to overcome most of these complications, mainly pseudoaneurysm lesions and recoarctations (7-9’.
SC
Moreover, many of the published literature have used this type of stent as first choice treatment (2-3, 7-9’ in native coarctations rather than uncovered stent,
M AN U
wondering whether this should also be the case in candidates for endovascular treatment.
TE D
Chang Zong-Ping et al treated 25 patients with balloon-expandable covered stent in native coarctations. No complications were reported, neither acute nor
EP
during the 72-month follow-up period (3’.
AC C
Our patient s characteristic feature were her age, 82 years, and the presence of a concomitant aneurysm due to the hemodynamic stress caused by high flow jet streamafter the coarctation (10’. As the two lesions had to be treated, and given the anatomical features (aortic arch angle and diameter, and lesions length’, the aortic endoprosthesis option was chosen. In our opinion, the selfexpanding stent would better suit the anatomy, with all the lesions being
ACCEPTED MANUSCRIPT covered before achieving the maximum coarctation expansion using balloon angioplasty due to the prolonged evolution of the disease, as an aortic rupture
RI PT
could not have been easily avoided. Several series of cases reported the use of aortic endoprostheses for the
SC
endovascular treatment of post surgical pseudoaneurysms (11-16’. However, the use of this type of devices for the treatments of native coarctations in
M AN U
patients as the one herein described is rare. Furthermore, this is the first report of endovascular treatment in an octogenarian patient with native coarctation
TE D
and a concomitant aortic aneurysm.
In our opinion, self-expanding stents offer several advantages over balloon-
EP
expandable stents. The former have better conformability in the aortic arch,
AC C
which is usually hypoplastic; are less traumatic, and therefore suit better the vascular anatomy. Furthermore, they are available in several lengths, being useful for coarctations associated with aneurysms where a longer length must be covered to avoid the overlap between devices, which could result in endoleak formation. Thus, these stents allow the highest coarctation dilation, with the whole lesion being covered, reducing the risk of hemorrhagic
ACCEPTED MANUSCRIPT complications. Even though we have limited experience, we agree with Kenny D et al (8’ that in patients with an aortic coarctation and a concomitant aneurysm,
the aortic arch has a favorable anatomy.
SC
COI Disclosure Statement
Author #3 no conflict of interest
TE D
Author #4 no conflict of interest
M AN U
Author #1 no conflict of interest Author #2 no conflict of interest
AC C
EP
Author #5 no conflict of interest
RI PT
the self-expanding stent should be the first choice for treatment, provided that
ACCEPTED MANUSCRIPT REFERENCES 1.
Campbell M. Natural history of coarctation of the aorta. Br Heart J1970
RI PT
Sep;32(5’:633-40. 2.
Jurcut R, Daraban AM, Lorber A, Deleanu D, Amzulescu MS, Zara C,
SC
Popescu BA, Ginghina C. Coarctation of the aorta in adults: what is the best treatment? Case report and literature review. J Med Life2011 May 15;4(2’:189-
3.
M AN U
95.
Chang ZP, Jiang SL, Xu ZY, Zhang GJ, Huang LJ, Zhao SH, Ling J,
TE D
Zheng H, Jin JL, Wu WH, Hu HB, Li SG, Yu JH, Yan CW. Use of covered Cheatham-Platinum stent as the primary modality in the treatment for native
Victor
S.
Patch
aortoplasty
for
coarctation
of
aorta:
technical
AC C
4.
EP
coarctation of the aorta. Chin Med J (Engl’2012 Mar;125(6’:1005-9.
considerations. Ann Thorac Surg1995 May;59(5’:1276-8. 5.
Vitullo DA, DeLeon SY, Graham LC, Eidem BW, Roughneen PT,
Javorski JJ, Cetta F. Extended end-to-end repair and enlargement of the entire arch in complex coarctation. Ann Thorac Surg1999 Feb;67(2’:528-31.
ACCEPTED MANUSCRIPT 6.
Wheatley GH, 3rd, Koullias GJ, Rodriguez-Lopez JA, Ramaiah VG,
Diethrich EB. Is endovascular repair the new gold standard for primary adult
RI PT
coarctation? Eur J Cardiothorac Surg2010 Sep;38(3’:305-10. 7.
Butera G, Heles M, MacDonald ST, Carminati M. Aortic coarctation
SC
complicated by wall aneurysm: the role of covered stents. Catheter Cardiovasc Interv2011 Nov 15;78(6’:926-32.
Kenny D, Margey R, Turner MS, Tometzki AJ, Walsh KP, Martin RP.
M AN U
8.
Self-expanding and balloon expandable covered stents in the treatment of aortic
Jul 1;72(1’:65-71.
Tanous D, Collins N, Dehghani P, Benson LN, Horlick EM. Covered
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9.
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coarctation with or without aneurysm formation. Catheter Cardiovasc Interv2008
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stents in the management of coarctation of the aorta in the adult: initial results and 1-year angiographic and hemodynamic follow-up. Int J Cardiol2010 Apr 30;140(3’:287-95. 10.
Lin PY, Wu YT, Lin GC, Shih YH, Sampilvanjil A, Chen LR, Yang YJ, Wu
HL, Jiang MJ. Coarctation-induced degenerative abdominal aortic aneurysm in a porcine model. J Vasc Surg2013 Mar;57(3’:806-15 e1.
ACCEPTED MANUSCRIPT 11.
Rabellino M, Zander T, Gonzalez G, Baldi S, Cheves H, Estigarribia A,
Llorens
R,
Carreira
JM,
Maynar
M.
Endovascular
treatment
for
RI PT
pseudoaneurysms after surgical correction of aortic coarctation. Cardiol Res Pract2011;2011:649207.
Ince H, Petzsch M, Rehders T, Kische S, Korber T, Weber F, Nienaber
SC
12.
CA. Percutaneous endovascular repair of aneurysm after previous coarctation
13.
M AN U
surgery. Circulation2003 Dec 16;108(24’:2967-70.
Marcheix B, Lamarche Y, Perrault P, Cartier R, Bouchard D, Carrier M,
TE D
Perrault LP, Demers P. Endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation. Eur J Cardiothorac
Kutty S, Greenberg RK, Fletcher S, Svensson LG, Latson LA.
AC C
14.
EP
Surg2007 Jun;31(6’:1004-7.
Endovascular stent grafts for large thoracic aneurysms after coarctation repair. Ann Thorac Surg2008 Apr;85(4’:1332-8. 15.
Botta L, Russo V, Oppido G, Rosati M, Massi F, Lovato L, Di Bartolomeo
R, Fattori R. Role of endovascular repair in the management of late pseudo-
ACCEPTED MANUSCRIPT aneurysms following open surgery for aortic coarctation. Eur J Cardiothorac Surg2009 Oct;36(4’:670-4. Midulla M, Dehaene A, Godart F, Lions C, Decoene C, Serge W, Koussa
RI PT
16.
M, Rey C, Prat A, Beregi JP. TEVAR in patients with late complications of aortic
AC C
EP
TE D
M AN U
SC
coarctation repair. J Endovasc Ther2008 Oct;15(5’:552-7.
ACCEPTED MANUSCRIPT FIGURES Figure 1. A: MCTA 3D reconstruction depicting post-coarctation aneurysmatic
RI PT
dilation and ample collateral circulation through internal and intercostal mammary arteries. B: enlarged image showing both aneurysmatic dilation and
SC
hypertrophic bronchial arteries. C: Multiplanar reconstruction showing aortic coarctation stenosis.
M AN U
Figure 2. A: Thoracic aorta angiography showing the coarctation using post stenotic contrast jet (white arrow’, and distal aortic aneurysm developed after
TE D
coarctation using less staining. B: Late image showing contrast medium wash of ascending aorta, and staining of the aorta (aortic arch’ after coarctation. Notice
EP
the predominance of collateral circulation such as the hyertrophic bronchial
AC C
artery. C: Fluoroscopic image of the coarctation pre-dilation using a 10 mm diameter balloon. D: Fluoroscopic image of the control angioplasty using 15 mm balloon after the placement of and endoprothesis. E: Angiography showing full coarctation widening without collateral circulation. Figure 3. A: MCTA 3 D reconstruction showing endoprothesis permeability and the absence of collateral circulation. B: MCTA multiplanar reconstruction
ACCEPTED MANUSCRIPT depicting full expansion at the previous site of the coarctation maximum stenosis. No difference in diameter is observed between the latter and the aortic
RI PT
segment before the coarctation. C: The aneurysmatic sac, was thrombosed with no evidence of endoleak. D: Maximum intensity projection (MIP’ image of the
SC
endoprosthesis showing full expansion at the site of the coarctations maximum
AC C
EP
TE D
M AN U
stenosis.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0890-5096(15)00621-4
DOI:
10.1016/j.avsg.2015.06.084
Reference:
AVSG 2505
To appear in:
Annals of Vascular Surgery
Received Date: 1 May 2015 Accepted Date: 11 June 2015
Please cite this article as: Rabellino M, Kotowicz V, Kenny A, Kohan AA, García-Mónaco R, Aortic Endoprosthesis for the Treatment of Native Aortic Coarctation and Concomitant Aneurysm in an Octogenarian Patient, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.06.084. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT AORTIC ENDOPROSTHESIS FOR THE TREATMENT OF NATIVE AORTIC COARCTATION AND CONCOMITANT ANEURYSM IN AN OCTOGENARIAN
RI PT
PATIENT
Case Report
SC
Martín Rabellino MD1, Vadim Kotowicz MD2, Alberto Kenny1, Andres Alejandro
M AN U
Kohan MD1, Ricardo García-Mónaco MD1.
1. Department of Interventional Radiology. Hospital Italiano. Buenos Aires (Argentina’
TE D
2. Department of Cardiovascular Surgery. Hospital Italiano. Buenos Aires (Argentina’
Institutional affiliation:
EP
Hospital Italiano de Buenos Aires
AC C
Juan D Peron 3190 CP:C1181ACH, Buenos Aires, Argentina 5411 4959-0595
[email protected] [email protected] [email protected]
ACCEPTED MANUSCRIPT [email protected]
RI PT
[email protected]
Correspondence to:
SC
Martín Rabellino
4190, Buenos Aires, Argentina.
M AN U
Department of Radiology, Hospital Italiano de Buenos Aires, C/ Pte. J. D. Perón
Phone: 54-11-4959-0453, ext. 8347
TE D
Fax: 54-11-4959-0471 or 54-11-4959-0200
EP
E-mail: [email protected]
AC C
Short running title: Endovascular treatment of an octogenarian patient with a concomitant aortic coarctation and post-stenotic aneurysm.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
EP
AORTIC ENDOPROSTHESIS FOR THE TREATMENT OF NATIVE AORTIC
AC C
COARCTATION AND CONCOMITANT ANEURYSM IN AN OCTOGENARIAN PATIENT
ABSTRACT
We report a case of an 82-year-old female patient with native coarctation of the aorta and post-stenotic aneurysm of the descending thoracic aorta. Upon consultation she was receiving four antihypertensive drugs and physical
ACCEPTED MANUSCRIPT examination revealed non-palpable lower limb pulses with intermittent claudication at 50 m. Because of her age, high surgical risk and combination of
RI PT
lesions, endovascular treatment was suggested. Placement of a Valiant thoracic aorta endoprosthesis followed by coarctation angioplasty was performed. At 48
SC
hours, the patient was discharged on one antihypertensive drug, palpable pulses on both limbs and a normal ankle-brachial index. At one month follow-up
M AN U
the patient remained as discharged and multislice computed tomography angiography depicted complete coarctation expansion without residual stenosis,
TE D
exclusion of the aortic aneurysm, and no signs of endoleaks.
AC C
EP
Key Words: Aortic coarctation, aortic endoprosthesis, aortic aneurysm
ACCEPTED MANUSCRIPT INTRODUCTION
Coarctation of the aorta has a reported incidence between 5-8% in patients with
RI PT
congenital heart anomalies (1’. Mean age of mortality in patients that did not undergo corrective surgery is 35 years. Ninety per cent of them die before 50
SC
years of age due to systemic hypertension, coronary disease, aortic dissection,
M AN U
stroke and congestive cardiac failure (1’. Therefore, native coarctation of the aorta is very rare in adults and is generally secondary to recoarctations occurring after open or endovascular surgery (2’.
TE D
Treatment options include open and endovascular surgery. In the latter, the most common techniques are angioplasty, uncovered stent and, more recently,
EP
covered stent, which is supposed to reduce complications associated with the
AC C
other two endovascular techniques (3’. We report an 82-year-old female patient who presented with a native coarctation and concomitant aortic aneurysm, which were treated with aortic endoprosthesis. CASE REPORT
ACCEPTED MANUSCRIPT Eighty-two-year-old female patient with a history of arterial hypertension secondary to aortic coarctation diagnosed at adolescence. On a routine chest
RI PT
X-Ray ordered by her physician a widened mediastinum is seen. To further study the X-Ray findings, a multidetector computed tomography angiography
SC
(MCTA’ is ordered (Fig. 1 A-C’, revealing an aortic coractation of the descending aorta beneath the left subclavian artery, with a 5cm wide post-
M AN U
stenotic aneurysm. Due to the MCTA findings and her age, she is referred to our department for eventual treatment. Upon consultation she was currently
TE D
receiving four antihypertensive drugs, atenolol 50 mg/d, enalapril 10 mg/d, hydrochlorothiazide 25 mg/d and amlodipine 10 mg/d. Physical examination,
EP
showed no palpable pulses on her lower limbs, bilateral intermittent claudication
AC C
at 50 m and bilateral 0.4 ankle-brachial index (ABI’. Due to the complexity of both lesions, her age and the favorable anatomical characteristics of her aorta endovascular treatment is offered consisting of an aortic endoprothesis. . The procedure was done under systemic heparinization 100 U/I/k weight. Under general anesthesia she underwent right common femoral artery dissection and right brachial artery percutaneous puncture. A 5 French catheter was placed to
ACCEPTED MANUSCRIPT further insert a pig-tail catheter all the way into the ascending aorta. This allowed both a diagnostic angiography of the thoracic aorta (Fig 2A-B’, and
RI PT
angiographic control during the procedure. Through the arteriotomy, a 5 French vertebral hydrophilic catheter used to
SC
overcome the coarctation is inserted on a 0.035 hydrophilic guidewire. Pressures prior and distal to the stenosis were analyzed, and a 95 mmHg
M AN U
gradient is obtained.
A Lundequist guidewire was inserted up to the ascending aorta, on which a 10
TE D
mm angioplasty balloon was placed for dilation of the coarctation, which, as MCTA showed, had a 5 mm diameter. Afterwards, a Valiant thoracic aorta
EP
endoprosthesis (Valiant Captivia®, Medtronic’ measuring 24x24x150 mm was
AC C
inserted and used to cover both the coarctation and the aneurysm. Another angioplasty is then performed using a balloon with a 15 mm diameter (Fig 2D’. Angiographic control after the procedure depicted full expansion of the stenotic lesion, with no signs of residual stenosis, no further translesional pressure gradient, aneurysm exclusion, and no evidence of type II endoleak through the collaterals (Fig 3A-B’. The patient had a favorable recovery, with no
ACCEPTED MANUSCRIPT complications after surgery. Furthermore, 3 antihypertensive drugs were discontinued immediately after the procedure, with her blood pressure
RI PT
remaining within normal parameters. At 48 h the patient was discharged home on one antihypertensive drug and aspirin 100 mg/d. Upon physical examination
SC
both limbs had palpable pulses with an ABI of 1. The patient returned for control one week later referring no further intermittent claudication. A control MCTA
M AN U
performed one month after the procedure depicted absence of residual stenosis, exclusion and thrombosis of the aneurysmatic sac, no evidence of
DISCUSSION
TE D
leaks and no further collateral circulation (Fig 3E’.
EP
Over the last decades, there have been great advances in the surgical
AC C
treatment of aortic coarctation. From the first surgery carried out by doctors Crawford and Nylin in 1944 to date, surgical techniques have improved (4-5’, with the inclusion of the endovascular treatment as an option. The results of these types of treatments in adult patients are comparable to those offered by open surgery in patients with native aortic coarctations (6’. Despite being a great advancement, all these techniques are associated with immediate and
ACCEPTED MANUSCRIPT late complications, such as dissections, arterial ruptures, neurological complications, stent migration, pseudoaneurysms, recoarctations and death.
RI PT
Covered stent has recently emerged as an option to overcome most of these complications, mainly pseudoaneurysm lesions and recoarctations (7-9’.
SC
Moreover, many of the published literature have used this type of stent as first choice treatment (2-3, 7-9’ in native coarctations rather than uncovered stent,
M AN U
wondering whether this should also be the case in candidates for endovascular treatment.
TE D
Chang Zong-Ping et al treated 25 patients with balloon-expandable covered stent in native coarctations. No complications were reported, neither acute nor
EP
during the 72-month follow-up period (3’.
AC C
Our patient s characteristic feature were her age, 82 years, and the presence of a concomitant aneurysm due to the hemodynamic stress caused by high flow jet streamafter the coarctation (10’. As the two lesions had to be treated, and given the anatomical features (aortic arch angle and diameter, and lesions length’, the aortic endoprosthesis option was chosen. In our opinion, the selfexpanding stent would better suit the anatomy, with all the lesions being
ACCEPTED MANUSCRIPT covered before achieving the maximum coarctation expansion using balloon angioplasty due to the prolonged evolution of the disease, as an aortic rupture
RI PT
could not have been easily avoided. Several series of cases reported the use of aortic endoprostheses for the
SC
endovascular treatment of post surgical pseudoaneurysms (11-16’. However, the use of this type of devices for the treatments of native coarctations in
M AN U
patients as the one herein described is rare. Furthermore, this is the first report of endovascular treatment in an octogenarian patient with native coarctation
TE D
and a concomitant aortic aneurysm.
In our opinion, self-expanding stents offer several advantages over balloon-
EP
expandable stents. The former have better conformability in the aortic arch,
AC C
which is usually hypoplastic; are less traumatic, and therefore suit better the vascular anatomy. Furthermore, they are available in several lengths, being useful for coarctations associated with aneurysms where a longer length must be covered to avoid the overlap between devices, which could result in endoleak formation. Thus, these stents allow the highest coarctation dilation, with the whole lesion being covered, reducing the risk of hemorrhagic
ACCEPTED MANUSCRIPT complications. Even though we have limited experience, we agree with Kenny D et al (8’ that in patients with an aortic coarctation and a concomitant aneurysm,
the aortic arch has a favorable anatomy.
SC
COI Disclosure Statement
Author #3 no conflict of interest
TE D
Author #4 no conflict of interest
M AN U
Author #1 no conflict of interest Author #2 no conflict of interest
AC C
EP
Author #5 no conflict of interest
RI PT
the self-expanding stent should be the first choice for treatment, provided that
ACCEPTED MANUSCRIPT REFERENCES 1.
Campbell M. Natural history of coarctation of the aorta. Br Heart J1970
RI PT
Sep;32(5’:633-40. 2.
Jurcut R, Daraban AM, Lorber A, Deleanu D, Amzulescu MS, Zara C,
SC
Popescu BA, Ginghina C. Coarctation of the aorta in adults: what is the best treatment? Case report and literature review. J Med Life2011 May 15;4(2’:189-
3.
M AN U
95.
Chang ZP, Jiang SL, Xu ZY, Zhang GJ, Huang LJ, Zhao SH, Ling J,
TE D
Zheng H, Jin JL, Wu WH, Hu HB, Li SG, Yu JH, Yan CW. Use of covered Cheatham-Platinum stent as the primary modality in the treatment for native
Victor
S.
Patch
aortoplasty
for
coarctation
of
aorta:
technical
AC C
4.
EP
coarctation of the aorta. Chin Med J (Engl’2012 Mar;125(6’:1005-9.
considerations. Ann Thorac Surg1995 May;59(5’:1276-8. 5.
Vitullo DA, DeLeon SY, Graham LC, Eidem BW, Roughneen PT,
Javorski JJ, Cetta F. Extended end-to-end repair and enlargement of the entire arch in complex coarctation. Ann Thorac Surg1999 Feb;67(2’:528-31.
ACCEPTED MANUSCRIPT 6.
Wheatley GH, 3rd, Koullias GJ, Rodriguez-Lopez JA, Ramaiah VG,
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ACCEPTED MANUSCRIPT FIGURES Figure 1. A: MCTA 3D reconstruction depicting post-coarctation aneurysmatic
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dilation and ample collateral circulation through internal and intercostal mammary arteries. B: enlarged image showing both aneurysmatic dilation and
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hypertrophic bronchial arteries. C: Multiplanar reconstruction showing aortic coarctation stenosis.
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Figure 2. A: Thoracic aorta angiography showing the coarctation using post stenotic contrast jet (white arrow’, and distal aortic aneurysm developed after
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coarctation using less staining. B: Late image showing contrast medium wash of ascending aorta, and staining of the aorta (aortic arch’ after coarctation. Notice
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the predominance of collateral circulation such as the hyertrophic bronchial
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artery. C: Fluoroscopic image of the coarctation pre-dilation using a 10 mm diameter balloon. D: Fluoroscopic image of the control angioplasty using 15 mm balloon after the placement of and endoprothesis. E: Angiography showing full coarctation widening without collateral circulation. Figure 3. A: MCTA 3 D reconstruction showing endoprothesis permeability and the absence of collateral circulation. B: MCTA multiplanar reconstruction
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segment before the coarctation. C: The aneurysmatic sac, was thrombosed with no evidence of endoleak. D: Maximum intensity projection (MIP’ image of the
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endoprosthesis showing full expansion at the site of the coarctations maximum
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