THERAPY AND PREVENTION CONGENITAL HEART DISEASE Treatment of restenosis of coarctation by percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty (PTA) was used successfully to treat coarctation restenosis in seven patients. The patients were 10 months to 17 years old at the time of the angioplasty, and the initial coarctation repair had been performed 10 months to 161⁄2/2 years previously. PTA reduced the systolic pressure gradient across the coarctation from a mean of 58 mm Hg before the procedure to a mean of 13 mm Hg immediately after PTA. Follow-up has been from 1 to 14 months and indicates that the decrease in the systolic pressure gradient is persistent. Circulation 68, No. 5, 1087-1094, 1983. SURGICAL REPAIR of coarctation of the aorta has been performed since 1945. Recent reviews have indicated that there is a high incidence of recurrence of stenosis at the anastomotic site, particularly if the primary repair is performed in infancy. 1-8 If surgical correction is delayed into later childhood, there would be a risk of persistent hypertension, although the risk of recurrent stenosis would be lessened.9' '° The mechanism of recurrence of stenosis at the coarctation site has been considered to be the result of one or more factors: (1) incomplete relief of the obstruction at the time of the initial repair, (2) incomplete resection of "abnormal" aortic tissue that may have a tendency to proliferate, (2) failure of the anastomotic site to grow, (4) thrombus formation on the suture line, and (5) intimal and medial hyperplasia at the anastomotic site.3 ' Surgical correction of coarctation restenosis can now be performed with an acceptable risk. 12-14 However, with the availability of large, nondistensible, polyethylene, dilatation balloon catheters'5 (Medi-Tech, Watertown, MA), percutaneous transluminal angioplasty (PTA) was considered as an alternative mode of therapy for the management of recurrent coarctation of the aorta. This article describes our experience and technique in successfully treating seven patients with coarctation restenosis. From the Departments of Pediatrics, Radiology, and Surgery, The Johns Hopkins Hospital, Baltimore. Address for correspondence: Jean S. Kan, M.D., Division of Pediatric Cardiology, The Helen B. Taussig Children's Heart Center, The Johns Hopkins Hospital, Baltimore, MD 21205. Received March 7, 1983; revision accepted July 7, 1983. Vol. 68, No. 5, November 1983 Methods Clinical material. Seven patients underwent percutaneous transluminal balloon angioplasty for treatment of recurrent stenosis in the aorta at the site of previous coarctation repair. The presenting data for these seven patients before the balloon angioplasty are summarized in table 1. The seven patients were divided into four categories based on the type of primary repair performed. Coarctation restenosis (end-to-end anastomosis, three patients) Patient 1. An 11-year-old girl had been in congestive heart failure in infancy. When she was 6 months old, a cardiac catheterization revealed severe coarctation of the aorta with a patent ductus arteriosus (PDA). Intra-aortic pressures indicated a 50 mm Hg pressure gradient across the coarctation. At 9 months of age she had surgical resection of the coarctation with an end-toend anastomosis. Subsequently she was asymptomatic, and when followed up in the outpatient clinic she had normal arm blood pressures and a 20 mm Hg lower pressure in her legs. At 11 years old, she had evidence of upper-extremity hypertension with diminished femoral pulses. Patient 2. An 8-year-old boy had been in congestive heart failure in the neonatal period. When he was 11 days old, cardiac catheterization revealed severe coarctation of the aorta and PDA. When he was 12 days old the coarctation was resected and an end-to-end anastomosis was performed. After the surgical procedure he had persistent upper-extremity hypertension with decreased femoral pulses. When he was 8 years old, cardiac catheterization revealed a discrete recurrent coarctation of the aorta. Patient 3. An 8-year-old boy had congestive heart failure and differential cyanosis at 4 days of age. Cardiac catheterization revealed severe coarctation of the aorta and PDA. The coarctation was resected, the aorta was repaired with an end-to-end anastomosis, and the PDA was ligated. Subsequently the congestive heart failure resolved, but there was persistent right arm hypertension with diminished femoral artery pulses. Coarctation restenosis (end-to-end anastomosis, status after bypass graft, two patients) Patient 4. A 17-year-old boy had congestive heart failure at 1 month of age. Cardiac catheterization revealed coarctation of the aorta and PDA. At 2 months of age he underwent surgical 1087 by gest on A ril 6, 2017 http://ciajournals.org/ D ow nladed from