20: Stassen J, De Meester P, Troost E, Roggen L, Moons P, Gewillig M, Van De Bruaene A, Budts W. Covered stent placement for treatment of coarctation of the aorta: immediate and long-term results. Acta Cardiol. 2021 Jul;76(5):464-472. doi: 10.1080/00015385.2020.1838126. Epub 2020 Oct 28. PMID: 33108973
Watch Commentary by Dr. Helen Parry (Leeds, UK), section editor of ACHD Journal:
Coarctation of the aorta accounts for 5-8% of congenital heart disease. Ten per cent of infants who undergo surgical intervention need further intervention in adulthood. Balloon only angioplasty was a popular choice for these patients, but there was a high rate of recurrence. Aortic wall injury and obstruction of the aorta were also noted complications. Bare metal stents were also used in this context but were associated with aneurysm, rupture, dissection and death.
The use of covered stents in treatment of coarctation of the aorta has become more widely spread. The study provides a contribution to the literature regarding their safety and efficacy.
This was a single centre, retrospective, observational study. Adult patients were included if they had an invasive gradient across the coarctation of >= 20 mmHg, or if the luminal diameter at the coarctation was 50% or less of the vessel. Children included in the study according to their diagnosis of hypertension, in this study, classed as >95th centile in age and gender matched controls.
As this was a retrospective study, there was variability in the follow up involved. Most patients were seen around 3 months post procedure and variably thereafter. Data for the mean systolic blood pressure gradient between the right upper limb and left lower limb were extracted and analysed where available. Clinical records were assessed for post procedure antihypertensive medications and for complications relating to the insertion of the covered stent.
The numbers of patients included and followed up are shown in the figure below, which is a copy of the flow chart included in the paper:
The mean age of the patients involved was 23.9 years +/- 15.8. A total of 102 stents were deployed in 89 patients.
Peri-procedural complications were those occurring within the first 3 months. The peri-procedural complication rate was 4.5% relating to vascular issues at the access site. Four patients had late complications: 2 patients developed stent fractures requiring further procedures and 2 patients developed new aneurysms following stent insertion. Patients with very tight narrowing who had planned staged treatment were not classed as requiring re-intervention.
The mean systolic blood pressure gradient comparing the right upper limb and left lower limbs was 38 mmHg +/-24 mmHg, at 3 months; this had fallen to 10 +/- 20 mmHg and was 10 +/- 17 mmHg at 12 months. At latest follow up, the blood pressure gradient for 56 patients was practically non-existent at -7+/- 18 mmHg. The mean follow up period was 6.6 years +/-3.7 years.
Data regarding blood pressure medications were also assessed. Thirty patients were taking anti-hypertensive medications post stent, 13 of these patients had reduced these medications at 1 year follow up. The 26 patients who were hypertensive (>140/90 mmHg) but not receiving medications were normotensive without medication at 1 year post covered stent insertion. However, at latest follow up, roughly 20% of all subjects were on antihypertensive medications.
Positive aspects of the study:
- Real-world data
- Adds to the data available and will aid the consent process in providing formal numbers of patients who developed complications.
- Describes the expected improvement in mean blood pressure between the right upper and left lower limbs to allow comparison during follow up by other teams assessing the relative success of their procedures
- The retrospective nature if the study meant that patients were not followed up at regular intervals in a uniform way, making the post procedure imaging very variable and posing the question whether further complications actually occurred but were not discovered
- The single centre nature of the study makes it difficult to extrapolate findings for other units
- A significant number of patients were lost to follow up, making the data incomplete
- No patient characteristics were provided for the patients who developed late complications, which may have been helpful in identifying patients who were high risk