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Aortic rupture after balloon angioplasty of aortic coarctation
EDITORIAL
Aortic rupture after balloon aortic coarctation P. Syamasundar
angioplasty
Rao, MD Mczclison, Wis.
In this issue of the JOURNAL, Roberts et a1.l report fatal aortic rupture after balloon angioplasty of postsurgical recoarctation. With the increasing use of balloon angioplasty as a therapeutic alternative to surgery for both native and postoperative coarctations, it is important that we understand why aortic rupture occurs and take the necessary precautions to prevent such disasters. I will attempt to address these issues in this editorial. Aortic rupture has been reported in neonates, infants, children, and adults after balloon angioplasty of both native coarctations2-a and postoperative recoarctations.ls 7,8 Aortic disruption may remain asymptomatic and may become evident at the time of surgery5 or pathologic examination3 or it may present with acute symptoms.* It may also result in pseudoaneurysm formation.g Complete aortic disruption must be conceptually distinguished from tears of intimal and medial layers of aortic wall, which are produced by “controlled injury” of radial forces of the balloon during balloon angioplasty. The intimal and medial tears are the mechanisms by which enlargement of the coarcted aortic segment is achieved. The causes of aortic disruption may be difficult to delineate but appear to be related to manipulation of tips of guide wires or catheters in the vicinity of freshly dilated coarctation,2,6 traction produced by straightening of the balloon during inflation3 balloon rupture,? or overdistension of the aorta with balloons much larger than the aortic diameter.l, g-11 Apart From the Department of Pediatrics, Division of Pediatric Cardiology, University of Wisconsin Medical School and University of Wisconsin Children’s Hospital, Madison. Received for publication Aug. 31, 1992; accepted Oct. 1, 1992. Reprint requests: Dr. P. Syamasundar Rao, Division of Pediatric Cardiology, University of Wisconsin Children’s Hospital, H4/416 CSC 600 Highland Ave., Madison, WI 5379’2-4108. AM HEARTJ 1993;125:1205-1206. Copyright \a 1993 by Mosby-Year Book Inc. 000%8703/93/$1.00 + .lO 4/l/44051 *References TReferences
of
1, 2, 4, 6-8. 1, 6, 8, 10, 11.
from clinical observations reported by several groups of researchers,ieg the experimental datalo, l1 clearly indicate that aortic disruption is likely to occur: (1) when a balloon, even of a diameter similar to that of the aortic lumen, is ruptured in the aorta and (2) when the aorta is overdistended with a balloon larger than the diameter of the aorta. We have had extensive clinical experience with balloon angioplasty of aortic coarctation, both native and postoperative,12-22 and have not observed aortic ruptures. Clear-cut understanding of the technique of balloon angioplasty and meticulous attention to the technique are absolutely necessary to prevent this and other types of complications. On the basis of our own experience12-22 and review of the reported experience related to this issue,l-i1 the following recommendations are made, which I hope, when applied appropriately, will prevent this disastrous complication. (1) It is vital to avoid manipulation of the tips of the guide wires and catheters in the region of freshly dilated aortic coarctation. A guide wire should always be left in place, over which exchange of subsequently needed catheters should be made. (2) Balloon inflation pressure should be monitored during angioplasty. There are many commercial devices available for this purpose. The reason for monitoring the pressure is not to prevent overinflation of the balloon (which is unlikely with the currently used noncompliant balloon material) but to prevent rupture of the balloons. The pressure of inflation recommended by the balloon catheter manufacturer should be followed. Under no circumstance should the burst pressure limit that is listed by the manufacturer be exceeded. (3) The size of the balloon chosen should not exceed the size of the aorta. Careful measurements of the coarcted aortic segment, aortic isthmus (or aortic segment proximal to the recoarctation site), and descending aorta at the level of the diaphragm should be obtained, and appropriate correction for magnification should be made. Although most researchers 1205
1206
April
Rao
use the catheter diameter for correction of magnification, other, better methods of magnification correction may provide more accurate measurements. The balloon size should be two or more times the size of the coarcted aortic segment but no larger than the descending aorta at the level of the diaphragm. We usually select a balloon size that is midway between the size of the aortic isthmus (or transverse aortic arch) and the size of the descending aorta at the level of the diaphragm. 23-25If an adequate improvement is not observed, a balloon as large as the descending aorta (at the level of the diaphragm) is chosen for additional dilatation.“3-“5 Careful selection of balloon size is important in preventing or reducing aortic ruptures and formation of aneurysms at the site of balloon dilatation. (4) Traction on the aorta during the straightening of the balloon while it is being inflated was mentioned3 as a cause of aortic tear. Unfortunately, however, there is always some degree of straightening of the balloon. To minimize this problem, we position the tip of the balloon catheter in the mid aortic arch rather than in the ascending aorta. (5) It should be recognized that there are going to be some aortic recoarctations and some native coarctations (particularly narrow isthmus) that are not amenable to balloon angioplasty. For these, surgical intervention, and perhaps stent deployment,s6 should be considered. In summary, aortic disruptions that cause disastrous consequences have been reported, and it appears that the majority of these are related to the technique of balloon angioplasty. Meticulous attention to the technique, including avoidance of manipulation of tips of guide wires and catheters at the site of coarctation dilatation, prevention of balloon ruptures, and selection of an appropriate-sized (no larger than the descending aorta at the level of the diaphragm) balloon is likely to prevent aortic rupture.
American
5.
6.
7.
8. 9.
10.
11.
12.
13. 14.
15.
16.
17.
18. 19. 20. 21.
22. REFERENCES 1. Roberts DH, Bellamy CM, Ramsdale DR. Fatal aortic rupture during balloon dilatation of recoarctation. AM HEART J 1993;125:1181-2. 2. Finley JP, Beaulieu RG, Nanton MA, Roy DL. Balloon catheter dilatation of coarctation of the aorta in young infants. Br Heart J 1983;50:411-5. 3. Krabill KA, Bass JL, Lucas RV Jr, Edwards JE. Dissecting transverse aortic arch aneurysm after percutaneous transluminal balloon dilation angioplasty of an aortic coarctation. Pediatr Cardiol 1987;8:39-42. 4. Kulick DL, Kotlewski A, Hurvitz RJ, Jamison M, Rahimtoola
23.
24. 25. 26.
Hean
1993
Journal
SH. Aortic rupture following percutaneous catheter balloon coarctoplasty in an adult. AM HEART J 1990;119:190-3. Booth P, Redington AN, Shinebourne EA, Rigby MI,. Early complications of interventional balloon catheterization in infants and children. Br Heart J 1991;65:109-12. Fawzy ME. Dunn B, Gala1 0, Wilson N, Shaikh A, Sriram K. Duran CMG. Balloon coarctation angioplasty in adolescents and adults: early and intermediate results. AM HEART .I 1992;124:16i-71. Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am d Cardiol 1990;65:793-7. Balaji S, Oommen R, Rees PG. Fatal aortic rupture during balloon dilatation of recoarctation. Br Heart J 1991:65:100-l. Joyce DH, McGrath LB. Pseudo-aneurysm formation following balloon angioplasty for recurrent coarctation of the aorta. Cathet Cardiovasc Diagn 1990;20:133-5. Lock JE, Castaneda-Zuniga WR, Bass JL, Foker JE, Amplatz K, Anderson RW. Balloon dilatation of excised aortic coarctations. Radiology 1982;143:689-91. Waller BF. Girod DA, Dillon JC. Transverse aortic wall tears in infants after balloon angioplasty for aortic valve stenosis: relation of aortic wall damage to diameter of inflated angioplasty balloon and aortic lumen in seven necropsy cases. J Am Co11 Cardiol 1984;4:1235-41. Rao PS. Transcat.heter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation. Br Heart d 1986;56:250-8. Rao PS. Balloon angioplasty for coarctation of the aorta in infancy. J Pediatr 1987;110:713-8. Rao PS, Najjar HN, Mardini MK, Solymar L, Thapar MK. Balloon angioplasty for coarctation of the aorta: immediate and long-term results. AM HEART J 1988;115:657-65. Rao PS. Thaaar MK. Kutavli F. Carev P. Causes of recoarctation follow&g balloon angioplasty of unoperated aortic cnarctations. ,J Am Co11 Cardiol 1989;13:109-15. Rao PS. Thapar MK, Gala1 0. Wilson AD. Follow-up results of balloon angioplasty of native coarctation in neonates and infants. AM HEART J 1990;120:1310-4. Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. AM HURT J 1990:120:1315-20. Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctat,ion. Ann Thorac Surg 1991;52:621-31. Rao PS. Fatal aortic rupt.ure during balloon dilatation of recoarctation fletter]. Br Heart J 1991;6Q406-7. Rao PS. Pseudoaneurysm following bafloon angioplasty? [Letter]. Cathet Cardiovasc Diagn 1991;23:150-3. Rao PS. Balloon angioplasty of native aortic coarctation. In: Rao PS, ed. Transcatheter t,herapy in pediatric cardiology. New York: Wiley-L&s, Chapter 10 (in press). Rao PS. Balloon angiopIasty for aortic recoarctation following previous surgery. In: Rao PS. ed. Transcatheter Therapy in Pediatric Cardiology. New York: Wiley-L&s: (in press): chap 11. Rao PS. Technique of balloon valvuloplasty/angioplasty. In: Rao PS, ed. Transcatheter therapy in pediatric cardiology. New York: Wiley-Liss; (in press): chap 4. Rao PS. Balloon angioplasty of aortic recoarctation [Letter]. Am J Cardiol (in press). Rao PS. Balloon angioplasty of native aortic coarctation [Let- _ ter]. J Am Co11 Cardiol 1992;20:749-52. O’Laughlin MP. Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation 1991; 83:1923-39.
Aortic rupture after balloon aortic coarctation P. Syamasundar
angioplasty
Rao, MD Mczclison, Wis.
In this issue of the JOURNAL, Roberts et a1.l report fatal aortic rupture after balloon angioplasty of postsurgical recoarctation. With the increasing use of balloon angioplasty as a therapeutic alternative to surgery for both native and postoperative coarctations, it is important that we understand why aortic rupture occurs and take the necessary precautions to prevent such disasters. I will attempt to address these issues in this editorial. Aortic rupture has been reported in neonates, infants, children, and adults after balloon angioplasty of both native coarctations2-a and postoperative recoarctations.ls 7,8 Aortic disruption may remain asymptomatic and may become evident at the time of surgery5 or pathologic examination3 or it may present with acute symptoms.* It may also result in pseudoaneurysm formation.g Complete aortic disruption must be conceptually distinguished from tears of intimal and medial layers of aortic wall, which are produced by “controlled injury” of radial forces of the balloon during balloon angioplasty. The intimal and medial tears are the mechanisms by which enlargement of the coarcted aortic segment is achieved. The causes of aortic disruption may be difficult to delineate but appear to be related to manipulation of tips of guide wires or catheters in the vicinity of freshly dilated coarctation,2,6 traction produced by straightening of the balloon during inflation3 balloon rupture,? or overdistension of the aorta with balloons much larger than the aortic diameter.l, g-11 Apart From the Department of Pediatrics, Division of Pediatric Cardiology, University of Wisconsin Medical School and University of Wisconsin Children’s Hospital, Madison. Received for publication Aug. 31, 1992; accepted Oct. 1, 1992. Reprint requests: Dr. P. Syamasundar Rao, Division of Pediatric Cardiology, University of Wisconsin Children’s Hospital, H4/416 CSC 600 Highland Ave., Madison, WI 5379’2-4108. AM HEARTJ 1993;125:1205-1206. Copyright \a 1993 by Mosby-Year Book Inc. 000%8703/93/$1.00 + .lO 4/l/44051 *References TReferences
of
1, 2, 4, 6-8. 1, 6, 8, 10, 11.
from clinical observations reported by several groups of researchers,ieg the experimental datalo, l1 clearly indicate that aortic disruption is likely to occur: (1) when a balloon, even of a diameter similar to that of the aortic lumen, is ruptured in the aorta and (2) when the aorta is overdistended with a balloon larger than the diameter of the aorta. We have had extensive clinical experience with balloon angioplasty of aortic coarctation, both native and postoperative,12-22 and have not observed aortic ruptures. Clear-cut understanding of the technique of balloon angioplasty and meticulous attention to the technique are absolutely necessary to prevent this and other types of complications. On the basis of our own experience12-22 and review of the reported experience related to this issue,l-i1 the following recommendations are made, which I hope, when applied appropriately, will prevent this disastrous complication. (1) It is vital to avoid manipulation of the tips of the guide wires and catheters in the region of freshly dilated aortic coarctation. A guide wire should always be left in place, over which exchange of subsequently needed catheters should be made. (2) Balloon inflation pressure should be monitored during angioplasty. There are many commercial devices available for this purpose. The reason for monitoring the pressure is not to prevent overinflation of the balloon (which is unlikely with the currently used noncompliant balloon material) but to prevent rupture of the balloons. The pressure of inflation recommended by the balloon catheter manufacturer should be followed. Under no circumstance should the burst pressure limit that is listed by the manufacturer be exceeded. (3) The size of the balloon chosen should not exceed the size of the aorta. Careful measurements of the coarcted aortic segment, aortic isthmus (or aortic segment proximal to the recoarctation site), and descending aorta at the level of the diaphragm should be obtained, and appropriate correction for magnification should be made. Although most researchers 1205
1206
April
Rao
use the catheter diameter for correction of magnification, other, better methods of magnification correction may provide more accurate measurements. The balloon size should be two or more times the size of the coarcted aortic segment but no larger than the descending aorta at the level of the diaphragm. We usually select a balloon size that is midway between the size of the aortic isthmus (or transverse aortic arch) and the size of the descending aorta at the level of the diaphragm. 23-25If an adequate improvement is not observed, a balloon as large as the descending aorta (at the level of the diaphragm) is chosen for additional dilatation.“3-“5 Careful selection of balloon size is important in preventing or reducing aortic ruptures and formation of aneurysms at the site of balloon dilatation. (4) Traction on the aorta during the straightening of the balloon while it is being inflated was mentioned3 as a cause of aortic tear. Unfortunately, however, there is always some degree of straightening of the balloon. To minimize this problem, we position the tip of the balloon catheter in the mid aortic arch rather than in the ascending aorta. (5) It should be recognized that there are going to be some aortic recoarctations and some native coarctations (particularly narrow isthmus) that are not amenable to balloon angioplasty. For these, surgical intervention, and perhaps stent deployment,s6 should be considered. In summary, aortic disruptions that cause disastrous consequences have been reported, and it appears that the majority of these are related to the technique of balloon angioplasty. Meticulous attention to the technique, including avoidance of manipulation of tips of guide wires and catheters at the site of coarctation dilatation, prevention of balloon ruptures, and selection of an appropriate-sized (no larger than the descending aorta at the level of the diaphragm) balloon is likely to prevent aortic rupture.
American
5.
6.
7.
8. 9.
10.
11.
12.
13. 14.
15.
16.
17.
18. 19. 20. 21.
22. REFERENCES 1. Roberts DH, Bellamy CM, Ramsdale DR. Fatal aortic rupture during balloon dilatation of recoarctation. AM HEART J 1993;125:1181-2. 2. Finley JP, Beaulieu RG, Nanton MA, Roy DL. Balloon catheter dilatation of coarctation of the aorta in young infants. Br Heart J 1983;50:411-5. 3. Krabill KA, Bass JL, Lucas RV Jr, Edwards JE. Dissecting transverse aortic arch aneurysm after percutaneous transluminal balloon dilation angioplasty of an aortic coarctation. Pediatr Cardiol 1987;8:39-42. 4. Kulick DL, Kotlewski A, Hurvitz RJ, Jamison M, Rahimtoola
23.
24. 25. 26.
Hean
1993
Journal
SH. Aortic rupture following percutaneous catheter balloon coarctoplasty in an adult. AM HEART J 1990;119:190-3. Booth P, Redington AN, Shinebourne EA, Rigby MI,. Early complications of interventional balloon catheterization in infants and children. Br Heart J 1991;65:109-12. Fawzy ME. Dunn B, Gala1 0, Wilson N, Shaikh A, Sriram K. Duran CMG. Balloon coarctation angioplasty in adolescents and adults: early and intermediate results. AM HEART .I 1992;124:16i-71. Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am d Cardiol 1990;65:793-7. Balaji S, Oommen R, Rees PG. Fatal aortic rupture during balloon dilatation of recoarctation. Br Heart J 1991:65:100-l. Joyce DH, McGrath LB. Pseudo-aneurysm formation following balloon angioplasty for recurrent coarctation of the aorta. Cathet Cardiovasc Diagn 1990;20:133-5. Lock JE, Castaneda-Zuniga WR, Bass JL, Foker JE, Amplatz K, Anderson RW. Balloon dilatation of excised aortic coarctations. Radiology 1982;143:689-91. Waller BF. Girod DA, Dillon JC. Transverse aortic wall tears in infants after balloon angioplasty for aortic valve stenosis: relation of aortic wall damage to diameter of inflated angioplasty balloon and aortic lumen in seven necropsy cases. J Am Co11 Cardiol 1984;4:1235-41. Rao PS. Transcat.heter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation. Br Heart d 1986;56:250-8. Rao PS. Balloon angioplasty for coarctation of the aorta in infancy. J Pediatr 1987;110:713-8. Rao PS, Najjar HN, Mardini MK, Solymar L, Thapar MK. Balloon angioplasty for coarctation of the aorta: immediate and long-term results. AM HEART J 1988;115:657-65. Rao PS. Thaaar MK. Kutavli F. Carev P. Causes of recoarctation follow&g balloon angioplasty of unoperated aortic cnarctations. ,J Am Co11 Cardiol 1989;13:109-15. Rao PS. Thapar MK, Gala1 0. Wilson AD. Follow-up results of balloon angioplasty of native coarctation in neonates and infants. AM HEART J 1990;120:1310-4. Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. AM HURT J 1990:120:1315-20. Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctat,ion. Ann Thorac Surg 1991;52:621-31. Rao PS. Fatal aortic rupt.ure during balloon dilatation of recoarctation fletter]. Br Heart J 1991;6Q406-7. Rao PS. Pseudoaneurysm following bafloon angioplasty? [Letter]. Cathet Cardiovasc Diagn 1991;23:150-3. Rao PS. Balloon angioplasty of native aortic coarctation. In: Rao PS, ed. Transcatheter t,herapy in pediatric cardiology. New York: Wiley-L&s, Chapter 10 (in press). Rao PS. Balloon angiopIasty for aortic recoarctation following previous surgery. In: Rao PS. ed. Transcatheter Therapy in Pediatric Cardiology. New York: Wiley-L&s: (in press): chap 11. Rao PS. Technique of balloon valvuloplasty/angioplasty. In: Rao PS, ed. Transcatheter therapy in pediatric cardiology. New York: Wiley-Liss; (in press): chap 4. Rao PS. Balloon angioplasty of aortic recoarctation [Letter]. Am J Cardiol (in press). Rao PS. Balloon angioplasty of native aortic coarctation [Let- _ ter]. J Am Co11 Cardiol 1992;20:749-52. O’Laughlin MP. Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation 1991; 83:1923-39.