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
- Coronary artery fistulas are rare and are heterogeneous in their anatomy and presentation.
- Clinically asymptomatic CAFs can be managed conservatively without long-term complications.
Commentary from Dr. Subhrajit Lahiri, section editor of Congenital Heart Disease Interventions Journal Watch:
The authors begin by stating the importance of transverse arch coarctation and evidence of successful percutaneous treatment in small studies. The objective of this paper was to evaluate the technical, procedural, and mid- and long-term clinical outcomes of percutaneous TAA stent implantation. This was a retrospective, international, multicenter study including patients who had percutaneous stent implantation to treat TAA obstruction from July 2002 to December 2017 at 4 centers. Procedural success was defined as a residual transcatheter gradient of ≤10 mm Hg. The author reports the placement of transverse aortic stents in 146 patients aged 12 months to 120 months. Technical success was achieved in 146 (100%) patients. On univariable analyses, lower patient weight (P=0.018), body surface area (P=0.013), and smaller Minimum Diameter /Descending AO ratio (P<0.001) were associated with a higher baseline Peak Systolic Ejection Gradient (PSEG). Postintervention PSEG was not associated with any patient or anatomic characteristic but was inversely associated with implant balloon (P<0.001) and final dilation (P<0.001) diameters. Of note, most of the stents used in this study were open-celled stents which prevent obstruction of flow to the head and neck vessels that are jailed in most of these cases.
The authors discussed the complications/risks in detail. The composite complication rate was 14%. This included stent embolization and intraprocedural aortic wall injuries. On univariable regression, the number of stents at the index procedure was the only variable associated with increased risk of intraprocedural complications (odds ratio, 4.58 [95% CI, 1.95–11.4]; P<0.001). The overall rate of postprocedural aortic wall injury and stent-related complications was 8.2% (n=12). There were no reports of abnormal brain imaging or cerebrovascular accidents immediately post-catheterization. Reintervention was reported in 60 (41%) patients at a median of 84 (22–148) months to first reintervention. Multivariate and univariate analysis showed that a residual gradient >10 mm Hg was associated with increased odds of reintervention at 1 year (odds ratio, 6.3 [95% CI, 1.5–26.8]; P=0.012) and from 1-year to most recent follow-up (odds ratio, 8.4 [95% CI, 2.2–56.1]; P=0.001). Interestingly, hypertension was present in 45% of patients at the latest follow up and the prescription of antihypertensive medications increased due to confidence that providers had to prescribe antihypertensive medications, once the coarctation was relieved by the intervention. This trend then plateaued.
The study can be criticized for the heterogeneity of the pathology, technique, and criteria of stent placement, the essence of which probably cannot be captured by the broad statistics performed. The blood pressure gradients reported were not granular to the level of arch vessels. Also, the lack of follow-up protocol probably fails to capture the exact prevalence of residual coarctation and long-term complications.
Nevertheless, this is the largest of similar studies which encourages us to consider transverse aortic arch stent placement in the selected population assuring good technical success and low recurrence and complication rates.
