Acute and medium term results of balloon expandable stent placement in the transverse arch-a multicenter pediatric interventional cardiology early career society study
Catheter Cardiovasc Interv 2020 Sep 9.
doi: 10.1002/ccd.29248. Online ahead of print.
PMID: 32902911; DOI: 10.1002/ccd.29248
Take Home Points:
- Transcatheter stenting of the transverse aortic arch (TAO) is feasible and with low incidence of major procedural complications.
- TAO stenting results in significant improvement in aortic arch gradient and narrowest arch diameter.
- TAO stenting in patients <10kg has an inherently high incidence of reinterventions and should only be used as a temporizing intervention to help achieve growth, recover ventricular function in a single ventricle, or resolution of other comorbidities.
- TAO stenting may benefit from 3D imaging of aortic arch obstruction to guide interventions.
Commentary from Dr. Arash Salavitabar (Ann Arbor, USA), section editor of Congenital Heart Disease Interventions Journal Watch: The authors addressed an important subgroup of patients, those with transverse aortic arch (TAO) obstruction, that often pose a difficult dilemma regarding whether transcatheter strategies can be utilized. This was a retrospective study from 7 centers from 7/2009 to 12/2017, designed to evaluate immediate and midterm results of TAO stent implantation.
TAO stenting was defined as stent placement proximal to the third head and neck vessel with the primary intention of treating narrowing in the transverse aorta. This did not include patients in whom the stent simply traversed the left subclavian artery in the absence of distal arch narrowing. Fifty-seven subjects were included at a median age of 14 years (4 days-42 years). Recoarctation following surgical repair was seen in 79% of patients and previous catheter-based therapy in 11%. The site of maximal narrowing was the isthmus in 35%, proximal transverse arch in 33%, distal transverse arch in 28%, and ascending aorta in 4% of patients. Gothic arches were seen in 25% of patients.
3D rotational angiography was utilized in 35% of cases. Femoral arterial access was used in 90% of cases, femoral venous in 5%, and carotid cutdown in 5% (all <5kg). Stents used were predominantly EV3 LD (Medtronic Inc, Minneapolis) (72%), followed by Palmaz Genesis XD (Cordis Inc Santa Clara Ca) (16%) and premounted [Herculink (Abbott Vascular, Abbott Park, IL) or Valeo (Bard Inc, Tempe, AZ)] (12%). One or more arch branches were jailed by the stent in 55 (96%) patients: left SCA covered in 53 (93%), left common carotid artery in 15 (26%), an aberrant right SCA in 2 (4%) and in 2 (4%) patients with previous subclavian artery flap coarctation repairs there was partial coverage of the left common carotid artery. There were 11 patients (21%) who required balloon angioplasty of the side cells of the stents to maximize patency of vessel origins (7 left common carotid, 3 left subclavian artery). The decisions to perform these interventions were up to the discretion of the interventional cardiologist.
There was significant improvement in transcatheter aortic arch gradient (p>0.001), narrowest arch diameter (p<0.001), and systolic BP pressure prior to discharge (p<0.001). There were 7 infants (all <6 months of age) at the time of intervention, 4 of which had recoarctation following a Norwood-type arch reconstruction. All of these patients had premounted stents placed. Surgical re-intervention was performed in 3 (43%) with surgical removal of stents and arch reconstruction. There were 3 (43%) mortalities: 2 with single ventricle physiology, one of which was after next staged surgical palliation and one due to worsening ventricular function, and one with native coarctation and genetic abnormalities. Patients with native coarctation were more likely to have smaller diameters of the ascending aorta, proximal transverse, and distal transverse arch. Patients with native coarctation were more likely to have a higher residual gradient post-intervention (p = .022). Complications included stent migration resulting in unintended jailing of the innominate artery in 2 patients (4%), hypotension warranting inotropic support in 2 patients (4%), pulse loss in 1 patient, and left arm brachial plexus injury in 1 patient.
Over the median follow-up of 38 months (0.4-7.3 years), 5 subjects died (all unrelated to the procedure) and there was 1 unplanned and 7 planned reinterventions (6 catheterizations, 2 surgeries). The surgeries were performed in patients in whom initial stenting took place at <1 months of age with the purpose to delay surgery. Antihypertensive medications were used in 27 (47%) patients prior to arch intervention and were continued in 23 (40%) patients at final follow-up. There were no cerebrovascular events or reports of subclavian steal syndrome during follow-up. Of note, there was no routine use of advanced brain imaging before and/or after TAO stenting.
The authors concluded that TAO stenting can be useful in select patients within minimal complications. However, systemic hypertension often continues to be an issue and requires medications despite resolution of TAO stenosis. As with all complex congenital lesions, a surgical approach must still be considered and the decision between surgical and transcatheter approaches should be made on an individualized basis.