Salavitabar A, Eisner M, Armstrong AK, Boe BA, Chisolm JL, Cheatham JP, Cheatham SL, Forbes T, Jones TK, Krings GJ, Morray BH, Steinberg ZL, Akam-Venkata J, Voskuil M, Berman DP. Circ Cardiovasc Interv. 2024 Jul;17(7):e013729. doi: 10.1161/CIRCINTERVENTIONS.123.013729. Epub 2024 Apr 26. PMID: 38666384
Take-home Points:
- Percutaneous stent implantation for treatment of transverse aortic arch obstruction has high rates of technical and procedural success.
- The procedure demonstrates a favorable safety profile with a low incidence of serious complications.
- Despite initial success, a considerable number of patients (41%) required reinterventions over time.
Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
This retrospective, international, multicenter study evaluated the efficacy and safety of percutaneous stent implantation for treating transverse aortic arch (TAA) obstruction. Conducted from July 2002 to December 2017, the study included 146 patients (median age 14.3 [IQR 9.3-19] years, weight 53 [IQR 30-69] kg, follow-up 53 [IQR 12–120] months), analyzing technical outcomes, procedural success, complications, and the necessity for subsequent reinterventions and long-term hypertension management. Technical and procedural success was defined by successful stent placement and a residual aortic arch gradient of ≤10 mmHg, respectively.
Most (74%) interventions were following a previous surgical or percutaneous procedure. The intervention exhibited a 100% technical success rate and an 88% procedural success rate. An arch vessel was overlapped by a stent in 81% of cases, most commonly the left subclavian artery (65%) and almost always (98%) intentionally. Balloon dilation of a stent side cell was performed in 22% of cases to improve flow to an arch vessel. Stent design, particularly the use of open cell stents, contributed to the overall success and adaptability of the procedure across varied anatomical challenges.
Complications (e.g. aortic injury, stent migration/fracture, vascular injury) during and immediately after the procedure occurred in 14% of cases, and during follow-up in 12% of cases. Notably, 41% of patients underwent reinterventions (47% balloon angioplasty of stents and 47% additional stent implantation), indicating a significant recurrence of aortic obstruction or related complications over time. A residual gradient >10 mmHg was associated with increased odds of reintervention.
Hypertension improved from baseline to most recent follow-up (68% to 46% of patients, p<0.05) with a concomitant increase in the use of antihypertensive medications (47% to 60% of patients, p<0.05).
This study, which has the largest sample size and longest follow-up to date, underscores the procedural reliability and clinical efficacy of percutaneous stent implantation in managing TAA obstruction. Despite a lack of strict inclusion and exclusion criteria, as well as a standardized approach to clinical and imaging follow-up, the study shows substantial improvements in medium to long-term outcomes. Nevertheless, the high rate of reinterventions calls for ongoing surveillance and management strategies to address related complications and the progressive nature of TAA obstruction.
