e-Herz: Case study Herz 2014 DOI 10.1007/s00059-013-3984-y Received: 24 April 2013 Revised: 29 August 2013 Accepted: 8 September 2013 © Urban & Vogel 2014
e-Herz
Aortic coarctation (AoC) is a congenital narrowing of the descending aorta, which is typically located at the insertion of the ductus arteriosus just distal to the left subclavian artery [1]. Severe cases may have complete loss of luminal continuity between the ascending and descending aortic segments. Progression of the luminal stenosis into totally occluded AoC has been reported in the literature [2, 3]. Owing to the close anatomic resemblance, the differential diagnosis of totally occluded AoC from interrupted aortic arch type A should be made before determining the treatment strategy [3]. Although surgical repair is the standard treatment for patients with totally occluded AoC, treatment with percutaneous covered stent implantation has been reported in a few cases in the literature [4]. We describe a totally occluded AoC treated with percutaneous covered stent implantation.
T. Seker · C. Türkoğlu · H. Uçar · M. Gür · D.Y. Şahin · M. Çaylı Department of Cardiology, Adana Numune Training and Research Hospital, Adana
Treatment of totally occluded aortic coarctation using a covered stent function. Contrast-enhanced computed tomography of the thorax clearly showed complete occlusion of the descending aorta after the subclavian artery and extensive collateral circulation. Aortic angiography via the right femoral and right radial arteries confirmed a total occlusion just behind the left subclavian artery (. Fig. 1a, b). We recommended surgery but the patient refused. We decided to perform percutaneous treatment of the totally occluded AoC with a graft stent. A 6F sheath was placed in the right femoral artery and a 6F multipurpose catheter was delivered to the distal part of the coarctation site on the descending aorta. Then, a 6F JR4 guiding catheter was placed into the proximal part of the coarctation site via left radial artery access. Aortic angiography was performed in antegrade and retrograde directions; the coarcted segment was totally occluded (. Fig. 2). The pressure gradient across the coarctation
segment was 110 mmHg. Firstly, we tried cross-occlusion with a 1.5×15-mm overthe-wire balloon (OTW) and a taperedtip hydrophilic-coated guidewire (Fielder XT, Asahi Intec, Japan) through the 6F JR4 guiding catheter antegradely. Nevertheless, we could not pass the coarctation segment with the Fielder XT guidewire and changed the Fielder XT guidewire with a tapered-tip stiff guidewire (Confianza pro 9.0, Asahi Intec). After this change, the Confianza pro 9.0 guidewire was passed through the totally occluded coarctation segment (. Fig. 3). Following predilation with the OTW balloon (. Fig. 4), we changed the Confianza pro 9.0 guidewire with a 0.014-in floppy guidewire; later, we extracted the OTW balloon. We further dilated the coarctation segment with a 4.0×20-mm monorail balloon (Invader PTCA, Alvimedica, Istanbul, Turkey) at 16 atm. Then, we retrogradely crossed the coarctation seg-
Case report A 23-year-old man was admitted to our hospital with headache and hypertension. On physical examination, his pulse rate was 88 bpm and blood pressure was 180/100 mmHg in the upper limbs. The radial pulses were palpable, but no pulse was found during palpation of the femoral arteries. Examination of the respiratory and other systems was normal. A grade 2/6 systolic ejection murmur could be heard along the left intercostal area and severe S1 sounds. Transthoracic echocardiography revealed normal left ventricular (LV) ejection fraction, LV hypertrophy, and grade I LV diastolic dys-
Fig. 1 8 a Aortography showing total occlusion of the aorta after the left subclavian artery via right radial artery access. b Aortography showing discontinuity of the aorta via right femoral artery access Herz 2014 |
1
e-Herz: Case study
Fig. 2 8 Bilateral injection showing totally occluded coarcted segment
Fig. 5 8 The covered stent position at the coarctation segment
Fig. 3 8 Aortography showing the guide-wire passing the totally occluded segment
Fig. 6 8 Imaging immediately after the covered stent implantation
nal angiography with antegrade contrast injections showed an excellent result (. Fig. 7, 8). The pressure gradient dropped to 5 mmHg. There was no complication during the procedure or after. Immediately after the stent placement, clinical re-evaluation showed palpable pulses of the dorsalis pedis, posterior tibial, popliteal, and femoral arteries. By the next day, the patient’s blood pressure was 120/70 mmHg without antihypertensive medications and he was discharged on aspirin at 300 mg/day for 6 months and clopidogrel at 75 mg/day for 4 weeks. We did not prescribe antihypertensive drugs to the patient at discharge. The patient remained well with a normal brachial blood pressure (120/80 mmHg) and preserved lowerlimb pulses at the 1-month follow-up. At the 1-year follow-up, physical examination was normal and brachial blood pressure was 125/80 mmHg without any medication. The patient also had a normal blood pressure range on ambulatory blood pressure monitoring (day-time: 132/86 mmHg; night-time: 117/67 mmHg; 24-h: 128/82 mmHg). Follow-up aortography was performed, which showed that the covered stent position was optimal and there was no in-stent restenosis (. Fig. 9).
Discussion
Fig. 4 8 Predilation with an over-the-wire balloon
Fig. 7 8 After dilatation with the Z-med balloon
ment with a multipurpose catheter via the right femoral artery and advanced the extrastiff guidewire through the multipurpose catheter. After this, we removed the floppy guidewire that was inside the 6F JL4 guiding catheter via the left radial artery. Thereafter, the 6F sheath in the right femoral artery was replaced with a 12F long sheath. Finally, we loaded an
18×40-mm covered stent (CheathamPlatinum, NuMed Inc., Hopkinton, NY, USA) over a BIB balloon and advanced the covered stent to the coarctation segment (. Fig. 5). The stent was implanted successfully (. Fig. 6). The pressure gradient dropped from 110 to 25 mmHg. A 20×50-mm Z-med balloon (NuMed Inc.) was gradually inflated three times and fi-
2 |
Herz 2014
Although totally occluded AoC bears close anatomic resemblance to interrupted aortic arch type A, the management of these congenital anomalies is different [3]. The differential diagnosis should be made before determining the treatment strategy. Various imaging methods can be used for the differential diagnosis. In totally occluded AoC, the ascending aorta retains its normal curvature and the distal aortic arch usually extends beyond the origin of the left subclavian artery. Unlike totally occluded AoC, the ascending aorta has usually a smaller caliber and a straight course to its branches in the interrupted aortic arch [3, 5]. Totally occluded AoC patients without correction have reduced life expectancy because of several complications such as hypertension, accelerated coronary heart disease, stroke, aortic dissection,
Fig. 9 9 Follow-up aortography at 1 year showing good stent position without instent restenosis
Fig. 8 8 Final angiographic image showing excellent result
and heart failure [6]. Although different methods are employed for the treatment of AoC in adults, open surgical repair is still the gold standard therapy for totally occluded AoC. Surgical mortality is rare (usually less than 1%). However, owing to significant collateralization through the intercostal arteries, these patients have increased surgical risk secondary to bleeding complications. Other early postoperative complications are paradoxical hypertension, aortic dissection, left recurrent laryngeal nerve paralysis, phrenic nerve injury, and subclavian steal [7]. Currently, endovascular procedures, especially covered stents, have been proposed as an alternative treatment for totally occluded AoC. The use of balloons or bare metal stents is not an option in these patients. Percutaneous covered stent implantation is less invasive and has a lower complication rate than surgery [8]. Covered stents have circular edges that are less traumatic to the vessel and therefore there is potentially less risk of dissection and aneurysm formation. We first recommended surgical repair to our patient, which he refused. We therefore decided to treat the patient with a covered stent. We passed the completely occluded segment with the material and techniques used in the standard treatment of coronary arteries showing chronic total occlusion. There are a few case reports in the literature on covered stent implantation in a completely occluded aortic coarctation [4, 9, 10, 11]. In cases of a very tight AoC, a staged approach—repeated balloon dilatation at intervals of 3–6 months—may be a safer option. However, we performed
aggressive dilatation of the stent during initial deployment without any complications in this case. It is known that blood pressure drops after the correction of AoC. In the literature, reduction or discontinuation of antihypertensive therapy following stent implantation is achieved in 41–88% of the patients [12]. Yazici et al. [13] reported that the mean systolic blood pressure declined from 154±9.7 mmHg to 130±7.3 mmHg immediately after the stent implantation in 15 patients with AoC. Jurcut et al. [12] decreased the antihypertensive drugs dose immediately after the stent implantation in a patient with AoC. In our case, the patient’s blood pressure was 120/70 mmHg without antihypertensive medications after the stent implantation and we did not prescribe antihypertensive drugs at discharge and at the 1-month follow-up. However, all patients treated with stent implantation should be monitored closely for recurrence of hypertension for longer followup periods. Follow-up with magnetic resonance imaging or computed tomography should be done for the evaluation of patients with late complications such as aneurysm and recurrent CoA [4].
Conclusion Percutaneous covered stent implantation is a safe and effective alternative treatment option to surgery in patients with totally occluded AoC. To pass the totally occluded segment, the material and techniques used in the standard treatment of chronic total occlusion of
coronary arteries can be used successfully during percutaneous treatment. All patients treated with stent implantation should be monitored closely.
Corresponding address T. Seker Department of Cardiology, Adana Numune Training and Research Hospital 01170 Adana Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. T. Seker, C. Türkoğlu, H. Uçar, M. Gür, D.Y. Şahin, and M. Çaylı state that there are no conflicts of interest. The accompanying manuscript does not include studies on humans or animals.
References 1. Hoffman JI (1995) Incidence of congenital heart disease: I. Postnatal incidence. Pediatr Cardiol 16(3):103–113 2. Kaneda T, Miyake S, Kudo T et al (2003) Obstructed coarctation in a right aortic arch in an adult female. Thorac Cardiovasc Surg 51:350–352 3. Vriend JW, Lam J, Mulder BJ (2004) Complete aortic arch obstruction: interruption or aortic coarctation? Int J Cardiovasc Imaging 20(5):393–396 4. Yazici HU, Ulus T, Temel K et al (2012) Percutaneous treatment of totally occluded the coarctation of the aorta with angioplasty and stenting. Eur Rev Med Pharmacol Sci 16(1):96–99 5. Perloff JK (1994) Coarctation of the aorta. In: The clinical recognition of congenital heart disease. W.B. Saunders Company, Philadelphia, S 132–169
Herz 2014
| 3
e-Herz: Case study 6. Warnes CA, Williams RG, Bashore TM et al (2008) ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 118:e714–e833 7. Bozzani A, Arici V, Ragni F (2013) Thoracic aorta coarctation in the adults: open surgery is still the gold standard. Vasc Endovascular Surg 47(3):216– 218. doi:10.1177/1538574413477218 (Epub) 8. Anagnaostopoulos-Tzifa A (2007) Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol 48:290–295 9. Kusa J, Szkutnik M, Biatkowski J (2008) Percutaneous reconstruction of the continuity of a functionally interrupted aortic arch using a stent. Cardiol J 15:80–84 10. Musso TM, Slack MC, Nowlen TT (2008) Balloon angioplasty with stenting to correct a functionally interrupted aorta: a case report with three-year follow-up. Catheter Cardiovasc Interv 72:87–92 11. Akdemir R, Agac MT, Acar Z (2010) Aortic coarctation: angioplasty and stenting of a total occlusion. Acta Cardiol 65(4):467–470. doi:10.2143/ AC.65.4.2053908 12. Jurcut R, Daraban AM, Lorber A et al (2011) Coarctation of the aorta in adults: what is the best treatment? Case report and literature review. J Med Life 4(2):189–195 (Epub) 13. Yazıcı HU, Göktekin O, Ulus T et al (2011) Our initial experience with stent implantation for aortic coarctation in adults. Turk Kardiyol Dern Ars 39(3):214–218. doi:10.5543/tkda.2011.01439
4 |
Herz 2014
e-Herz
Aortic coarctation (AoC) is a congenital narrowing of the descending aorta, which is typically located at the insertion of the ductus arteriosus just distal to the left subclavian artery [1]. Severe cases may have complete loss of luminal continuity between the ascending and descending aortic segments. Progression of the luminal stenosis into totally occluded AoC has been reported in the literature [2, 3]. Owing to the close anatomic resemblance, the differential diagnosis of totally occluded AoC from interrupted aortic arch type A should be made before determining the treatment strategy [3]. Although surgical repair is the standard treatment for patients with totally occluded AoC, treatment with percutaneous covered stent implantation has been reported in a few cases in the literature [4]. We describe a totally occluded AoC treated with percutaneous covered stent implantation.
T. Seker · C. Türkoğlu · H. Uçar · M. Gür · D.Y. Şahin · M. Çaylı Department of Cardiology, Adana Numune Training and Research Hospital, Adana
Treatment of totally occluded aortic coarctation using a covered stent function. Contrast-enhanced computed tomography of the thorax clearly showed complete occlusion of the descending aorta after the subclavian artery and extensive collateral circulation. Aortic angiography via the right femoral and right radial arteries confirmed a total occlusion just behind the left subclavian artery (. Fig. 1a, b). We recommended surgery but the patient refused. We decided to perform percutaneous treatment of the totally occluded AoC with a graft stent. A 6F sheath was placed in the right femoral artery and a 6F multipurpose catheter was delivered to the distal part of the coarctation site on the descending aorta. Then, a 6F JR4 guiding catheter was placed into the proximal part of the coarctation site via left radial artery access. Aortic angiography was performed in antegrade and retrograde directions; the coarcted segment was totally occluded (. Fig. 2). The pressure gradient across the coarctation
segment was 110 mmHg. Firstly, we tried cross-occlusion with a 1.5×15-mm overthe-wire balloon (OTW) and a taperedtip hydrophilic-coated guidewire (Fielder XT, Asahi Intec, Japan) through the 6F JR4 guiding catheter antegradely. Nevertheless, we could not pass the coarctation segment with the Fielder XT guidewire and changed the Fielder XT guidewire with a tapered-tip stiff guidewire (Confianza pro 9.0, Asahi Intec). After this change, the Confianza pro 9.0 guidewire was passed through the totally occluded coarctation segment (. Fig. 3). Following predilation with the OTW balloon (. Fig. 4), we changed the Confianza pro 9.0 guidewire with a 0.014-in floppy guidewire; later, we extracted the OTW balloon. We further dilated the coarctation segment with a 4.0×20-mm monorail balloon (Invader PTCA, Alvimedica, Istanbul, Turkey) at 16 atm. Then, we retrogradely crossed the coarctation seg-
Case report A 23-year-old man was admitted to our hospital with headache and hypertension. On physical examination, his pulse rate was 88 bpm and blood pressure was 180/100 mmHg in the upper limbs. The radial pulses were palpable, but no pulse was found during palpation of the femoral arteries. Examination of the respiratory and other systems was normal. A grade 2/6 systolic ejection murmur could be heard along the left intercostal area and severe S1 sounds. Transthoracic echocardiography revealed normal left ventricular (LV) ejection fraction, LV hypertrophy, and grade I LV diastolic dys-
Fig. 1 8 a Aortography showing total occlusion of the aorta after the left subclavian artery via right radial artery access. b Aortography showing discontinuity of the aorta via right femoral artery access Herz 2014 |
1
e-Herz: Case study
Fig. 2 8 Bilateral injection showing totally occluded coarcted segment
Fig. 5 8 The covered stent position at the coarctation segment
Fig. 3 8 Aortography showing the guide-wire passing the totally occluded segment
Fig. 6 8 Imaging immediately after the covered stent implantation
nal angiography with antegrade contrast injections showed an excellent result (. Fig. 7, 8). The pressure gradient dropped to 5 mmHg. There was no complication during the procedure or after. Immediately after the stent placement, clinical re-evaluation showed palpable pulses of the dorsalis pedis, posterior tibial, popliteal, and femoral arteries. By the next day, the patient’s blood pressure was 120/70 mmHg without antihypertensive medications and he was discharged on aspirin at 300 mg/day for 6 months and clopidogrel at 75 mg/day for 4 weeks. We did not prescribe antihypertensive drugs to the patient at discharge. The patient remained well with a normal brachial blood pressure (120/80 mmHg) and preserved lowerlimb pulses at the 1-month follow-up. At the 1-year follow-up, physical examination was normal and brachial blood pressure was 125/80 mmHg without any medication. The patient also had a normal blood pressure range on ambulatory blood pressure monitoring (day-time: 132/86 mmHg; night-time: 117/67 mmHg; 24-h: 128/82 mmHg). Follow-up aortography was performed, which showed that the covered stent position was optimal and there was no in-stent restenosis (. Fig. 9).
Discussion
Fig. 4 8 Predilation with an over-the-wire balloon
Fig. 7 8 After dilatation with the Z-med balloon
ment with a multipurpose catheter via the right femoral artery and advanced the extrastiff guidewire through the multipurpose catheter. After this, we removed the floppy guidewire that was inside the 6F JL4 guiding catheter via the left radial artery. Thereafter, the 6F sheath in the right femoral artery was replaced with a 12F long sheath. Finally, we loaded an
18×40-mm covered stent (CheathamPlatinum, NuMed Inc., Hopkinton, NY, USA) over a BIB balloon and advanced the covered stent to the coarctation segment (. Fig. 5). The stent was implanted successfully (. Fig. 6). The pressure gradient dropped from 110 to 25 mmHg. A 20×50-mm Z-med balloon (NuMed Inc.) was gradually inflated three times and fi-
2 |
Herz 2014
Although totally occluded AoC bears close anatomic resemblance to interrupted aortic arch type A, the management of these congenital anomalies is different [3]. The differential diagnosis should be made before determining the treatment strategy. Various imaging methods can be used for the differential diagnosis. In totally occluded AoC, the ascending aorta retains its normal curvature and the distal aortic arch usually extends beyond the origin of the left subclavian artery. Unlike totally occluded AoC, the ascending aorta has usually a smaller caliber and a straight course to its branches in the interrupted aortic arch [3, 5]. Totally occluded AoC patients without correction have reduced life expectancy because of several complications such as hypertension, accelerated coronary heart disease, stroke, aortic dissection,
Fig. 9 9 Follow-up aortography at 1 year showing good stent position without instent restenosis
Fig. 8 8 Final angiographic image showing excellent result
and heart failure [6]. Although different methods are employed for the treatment of AoC in adults, open surgical repair is still the gold standard therapy for totally occluded AoC. Surgical mortality is rare (usually less than 1%). However, owing to significant collateralization through the intercostal arteries, these patients have increased surgical risk secondary to bleeding complications. Other early postoperative complications are paradoxical hypertension, aortic dissection, left recurrent laryngeal nerve paralysis, phrenic nerve injury, and subclavian steal [7]. Currently, endovascular procedures, especially covered stents, have been proposed as an alternative treatment for totally occluded AoC. The use of balloons or bare metal stents is not an option in these patients. Percutaneous covered stent implantation is less invasive and has a lower complication rate than surgery [8]. Covered stents have circular edges that are less traumatic to the vessel and therefore there is potentially less risk of dissection and aneurysm formation. We first recommended surgical repair to our patient, which he refused. We therefore decided to treat the patient with a covered stent. We passed the completely occluded segment with the material and techniques used in the standard treatment of coronary arteries showing chronic total occlusion. There are a few case reports in the literature on covered stent implantation in a completely occluded aortic coarctation [4, 9, 10, 11]. In cases of a very tight AoC, a staged approach—repeated balloon dilatation at intervals of 3–6 months—may be a safer option. However, we performed
aggressive dilatation of the stent during initial deployment without any complications in this case. It is known that blood pressure drops after the correction of AoC. In the literature, reduction or discontinuation of antihypertensive therapy following stent implantation is achieved in 41–88% of the patients [12]. Yazici et al. [13] reported that the mean systolic blood pressure declined from 154±9.7 mmHg to 130±7.3 mmHg immediately after the stent implantation in 15 patients with AoC. Jurcut et al. [12] decreased the antihypertensive drugs dose immediately after the stent implantation in a patient with AoC. In our case, the patient’s blood pressure was 120/70 mmHg without antihypertensive medications after the stent implantation and we did not prescribe antihypertensive drugs at discharge and at the 1-month follow-up. However, all patients treated with stent implantation should be monitored closely for recurrence of hypertension for longer followup periods. Follow-up with magnetic resonance imaging or computed tomography should be done for the evaluation of patients with late complications such as aneurysm and recurrent CoA [4].
Conclusion Percutaneous covered stent implantation is a safe and effective alternative treatment option to surgery in patients with totally occluded AoC. To pass the totally occluded segment, the material and techniques used in the standard treatment of chronic total occlusion of
coronary arteries can be used successfully during percutaneous treatment. All patients treated with stent implantation should be monitored closely.
Corresponding address T. Seker Department of Cardiology, Adana Numune Training and Research Hospital 01170 Adana Turkey [email protected]
Compliance with ethical guidelines Conflict of interest. T. Seker, C. Türkoğlu, H. Uçar, M. Gür, D.Y. Şahin, and M. Çaylı state that there are no conflicts of interest. The accompanying manuscript does not include studies on humans or animals.
References 1. Hoffman JI (1995) Incidence of congenital heart disease: I. Postnatal incidence. Pediatr Cardiol 16(3):103–113 2. Kaneda T, Miyake S, Kudo T et al (2003) Obstructed coarctation in a right aortic arch in an adult female. Thorac Cardiovasc Surg 51:350–352 3. Vriend JW, Lam J, Mulder BJ (2004) Complete aortic arch obstruction: interruption or aortic coarctation? Int J Cardiovasc Imaging 20(5):393–396 4. Yazici HU, Ulus T, Temel K et al (2012) Percutaneous treatment of totally occluded the coarctation of the aorta with angioplasty and stenting. Eur Rev Med Pharmacol Sci 16(1):96–99 5. Perloff JK (1994) Coarctation of the aorta. In: The clinical recognition of congenital heart disease. W.B. Saunders Company, Philadelphia, S 132–169
Herz 2014
| 3
e-Herz: Case study 6. Warnes CA, Williams RG, Bashore TM et al (2008) ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 118:e714–e833 7. Bozzani A, Arici V, Ragni F (2013) Thoracic aorta coarctation in the adults: open surgery is still the gold standard. Vasc Endovascular Surg 47(3):216– 218. doi:10.1177/1538574413477218 (Epub) 8. Anagnaostopoulos-Tzifa A (2007) Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol 48:290–295 9. Kusa J, Szkutnik M, Biatkowski J (2008) Percutaneous reconstruction of the continuity of a functionally interrupted aortic arch using a stent. Cardiol J 15:80–84 10. Musso TM, Slack MC, Nowlen TT (2008) Balloon angioplasty with stenting to correct a functionally interrupted aorta: a case report with three-year follow-up. Catheter Cardiovasc Interv 72:87–92 11. Akdemir R, Agac MT, Acar Z (2010) Aortic coarctation: angioplasty and stenting of a total occlusion. Acta Cardiol 65(4):467–470. doi:10.2143/ AC.65.4.2053908 12. Jurcut R, Daraban AM, Lorber A et al (2011) Coarctation of the aorta in adults: what is the best treatment? Case report and literature review. J Med Life 4(2):189–195 (Epub) 13. Yazıcı HU, Göktekin O, Ulus T et al (2011) Our initial experience with stent implantation for aortic coarctation in adults. Turk Kardiyol Dern Ars 39(3):214–218. doi:10.5543/tkda.2011.01439
4 |
Herz 2014
