Balloon-expandable stent repair of severe coarctation of aorta

Experimental studies have shown that stents implanted at the aorta become incorporated within the aortic wall and can be further expanded in growing animals. This study evaluates the feasibility and immediate results of balloon-expandable stent implantation in 10 patients with severe coarctation of aorta. The ages of the patients ranged from 1 month to 43 years; 1 was an infant, 8 were children (mean age 5.3 +/- 4 years), and 1 was an adult. All had an unfavorable anatomy for balloon angioplasty; 9 had isthmus hypoplasia. Balloon predilation was first performed and its immediate effect evaluated. Then a balloon-expandable stent that was 30 mm long and covered the isthmus and coarctation levels was deployed, and it was further expanded to the preselected final diameter (12 +/- 4 mm). A final hemodynamic and angiographic evaluation was then obtained. Full deployment of an incompletely expanded and distally displaced stent in the infant led to aortic disruption that was controlled by a second stent covering the disrupted zone and the isthmus. After balloon angioplasty alone was done, the mean gradient (43 +/- 12 vs 31 +/- 10 mm Hg) and the percentage stenosis (72% +/- 11% vs 54% +/- 11%) had an insufficient decrease. However, after stent implantation was done, the gradient almost disappeared (mean 2 +/- 3 mm Hg). The angiographic stenosis disappeared in 7 patients and was markedly reduced in 3. The ratio of isthmus/descending aorta changed from 0.65 +/- 0.14 to 1 +/- 0.08 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Endaortitis of coarctation of the aorta after invasive diagnostics

We report the case of a young woman in whom endaortitis developed at the site of a coarctation of the aorta after the invasive investigation of right fossa iliac pain. The organism responsible suggests a causal relationship to the investigations without antibiotic prophylaxis, and we emphasize the need for antibiotic prophylaxis in these cases. Invasive investigation of isolated coarctation in a young adult or adolescent is probably superfluous.     

Vascular and neuroendocrine components in altered blood pressure regulation after surgical repair of coarctation of the aorta

STUDY OBJECTIVE: To investigate potential vascular and neuroendocrine determinants of altered blood pressure (BP) regulation in patients previously operated on for aortic coarctation. DESIGN, SETTING AND PATIENTS: We prospectively re-evaluated 45 patients operated on for aortic coarctation at Strasbourg University Hospital over a 13-year period. Four of these patients were less than 2 years old at the time of the operation and four were older than 20 years. Patient age and time since the operation were on average 21+/-13 years and 8+/-3 years, respectively. Surgery consisted of a resection with end-to-end anastomosis for 18 patients, angioplasty (8), prosthesis (4) or sub-clavian flap (15). RESULTS: Despite repair of the coarctation, about 40% of the patients showed an abnormal BP status at rest. The majority of these patients had uncomplicated borderline hypertension. The orthostasis test as well as the BP circadian rhythm were frequently abnormal. While the ankle/arm systolic pressure index measured at rest was generally within the normal range, diminished carotid-femoral pulse wave velocity was observed. Plasma adrenaline and aldosterone levels were elevated in about 50% of the patients examined. CONCLUSIONS: These new findings suggest that there are 'cause and effect' relationships between aortic structural and functional vascular abnormalities, and augmented plasma adrenaline and aldosterone in some patients after coarctation repair. These phenomena are likely to be involved in altered BP regulation and might result in recurrent hypertension.     

Follow-up after patch aortoplasty for coarctation of aorta

BACKGROUND: Patch aortoplasty (PA) for coarctation of aorta (COA) can lead to aneurysm formation at the repair site. X-ray, echocardiogram and computed tomography are unreliable for diagnosis of this complication. OBJECTIVE: To evaluate prospectively patients with PA for COA by magnetic resonance imaging (MRI) to detect presence of aneurysm at the repair site. DESIGN: All patients who underwent PA at the authors' institution were identified. MRI was performed in transverse and long axis oblique views on all patients except those who had, or were going to have, aortic angiography for other reasons. Details of the surgical procedure were obtained from the hospital records. RESULTS: Of the 18 patients studied, 15 had MRI and three had aortic angiography. Age at PA ranged from one week to 13.3 years (mean 6.3 years). The interval from PA to MRI or angiography was 9.5 years (range four to 12.5). No aneurysm was detected in any patient. Recoarctation was diagnosed in two patients not previously suspected but discovered on MRI. At PA the intimal shelf causing coarctation was either not excised or only minimally trimmed in 14 of 15 instances. CONCLUSIONS: The incidence of late aneurysm formation following PA for COA is low in the authors' patients, possibly due to minimal intimal damage at repair, although these patients should be followed longer. MRI was useful for assessment of aneurysm and restenosis.     

A case report of one-stage repair for transposition of the great arteries with intact ventricular septum and coarctation of the aorta in neonate

We report a neonatal case of one-stage repair for transposition of the great arteries with intact ventricular septum (TGA with IVS) and coarctation of the aorta (CoA). The surgery was performed at 27 days of age when the patient, a male, weighed 3408 g. Preoperative cardiac catheterization and angiography confirmed the diagnosis of TGA with IVS, CoA, atrial septal defect, patent ductus arteriosus, persistent left superior vena cava, left sided juxta-positioning of appendages and dextrocardia. The procedure was simultaneous subclavian flap aortoplasty through a left thoracotomy and an arterial switch operation through a median sternotomy. The patient's postoperative course was uneventful and he has grown well. Postoperative cardiac catheterization revealed mild pulmonary stenosis (pressure gradient of 19 mmHg between the right ventricle and the pulmonary artery) and mild aortic arch kinking from the arterial switch maneuver. One-stage repair, the combination of subclavian flap aortoplasty and arterial switch operation, provides a good clinical result in this complex malformation.     

A simple test to identify coarctation of the aorta

Despite the widespread recognition of coartation of the aorta there are still many patients in whome the diagnosis is not made. A simple clinical test which is useful in making the diagnosis in infants and adults, is described. It depends upon the differential color changes between fingers and toes after releasing a manual compression of feet and hands in the elevated position.     

Late results of patch repair of coarctation of the aorta in adults using autogenous arterial wall

BACKGROUND: Interposition grafting or patch repair of adult coarctations of the aorta are the standard methods of surgical treatment. Both involve use of prosthetic material, and patch repair using prosthetic material may lead to aneurysm formation in the long term. METHODS: Four patients aged 17 to 29 years had been investigated for systemic hypertension and had coarctation of the aorta diagnosed on cardiac catheterization. Between March and November 1984, all 4 underwent a corrective operation. The lesions were widely incised and a broad patch of ipsilateral mammary or Abbott's artery was fashioned across the narrowing. The arteries had been enlarged in diameter because of prolonged exposure to high blood pressure as collateral vessels, although none was intrinsically diseased. RESULTS: After 12 years of follow-up, only 1 patient remains on antihypertensive therapy. Spiral computed tomographic reconstructions revealed only very mild residual stenosis in 1 patient, confirmed by subsequent aortography. CONCLUSIONS: In adult patients with coarctation of the aorta, the use of the enlarged internal mammary artery as a patch graft is a simple, quick procedure, which may give lasting relief of obstruction. Spiral computed tomographic scanning is an ideal noninvasive method of follow-up.     

Bilateral internal mammary artery atherosclerosis: a late complication of delayed repair of coarctation of the aorta

A 58-year old patient who had undergone repair of aortic coarctation at 19 years of age, subsequently developed coronary artery disease requiring coronary artery bypass surgery. At operation both internal mammary arteries were found to be totally occluded with calcific atherosclerosis. We therefore advise that the internal mammary arteries should be assessed carefully in patients with similar past histories.     

Mitral valve repair in a patient with severe porcelain aorta

We repaired the mitral valve in a patient with severe porcelain aorta. Significant mitral regurgitation developed in a 66-year-old woman with heavy calcification throughout the whole aorta. At operation, cardiopulmonary bypass was properly established by combined axillary and femoral arterial cannulations for sufficient systemic flow. Likewise, the combination of a superior mitral approach and profound hypothermic fibrillatory arrest in conjunction with low-flow cardiopulmonary bypass allowed us to repair the mitral valve successfully.     

Extensive mesenteric inflammatory veno-occlusive disease of unknown etiology after primary cytomegalovirus infection: first case

We report a young man who, shortly after a primary cytomegalovirus infection, presented with signs of intestinal ischemia requiring surgical intervention. The resected specimen of small bowel showed striking features of extensive phlebitis and venulitis affecting virtually all of the veins of the small intestine and mesentery. Although he had had a recent primary cytomegalovirus viremia, we could not identify any evidence of cytomegalovirus in the small bowel. He was not infected with HIV. The entity we describe is different from the recently reported mesenteric inflammatory veno-occlusive disease. The clinicopathologic entity represented by our patient's disease was heretofore unrecognized.     

Aortic aneurysm complicated with coarctation of the aorta and Turner syndrome

A 23-year-old female with Turner syndrome and horse-shoe kidney underwent the operation of the coarctation of the aorta associated with the thoracic aortic aneurysm. The aortic aneurysm was located between the left carotid artery and the coarctation of the aorta, and the subclavian artery which was branched away from the aortic aneurysm was also aneurysmal. Aneurysmectomies and the reconstruction of the descending thoracic aorta and the left subclavian artery were performed with knitted Dacron grafts under assisting of the left atriodescending thoracic aortic bypass with Bio-pump. The disease was rare and such a case was not reported previously.     

Natural history of the residual infrarenal aorta after infrarenal abdominal aortic aneurysm repair

PURPOSE: We determined the natural history of the residual native infrarenal aortic segment after conventional abdominal aortic aneurysm (AAA) repair. METHODS: For the retrospective arteriographic case series, 800 hundred translumbar aortograms (TLAs) were obtained for 272 patients, before and after conventional AAA repair. The main outcome measures were changes in the aortographic diameter and the length of the infrarenal aortic segment, corrected and uncorrected for magnification by normalization to the first lumbar vertebral body height. RESULTS: The mean follow-up time from the preoperative TLA to the most recent postoperative TLA was 42 months (range, 1 to 257 months). Vertebral body height did not change (p = 0.35). The length of the native infrarenal aorta cephalad to the proximal anastomosis increased a mean of 3 mm, from 23 to 26 mm (p = 0.001). However, in 115 patients (43%), this aortic segment elongated more than 5 mm, and in 63 patients (24%), it elongated more than 10 mm. The native residual infrarenal aorta above the proximal anastomosis dilated a mean of 1 mm, from 23 to 24 mm (p = 0.001), but in 21 patients (8%), it dilated more than 5 mm. There was a weak positive correlation between the increase in residual native aortic diameter and duration of follow-up. There was a negative correlation between this increase and the initial size. The diameters of the proximal anastomosis and proximal graft did not change. Marked variability in the changes in aortic dimensions was observed. CONCLUSIONS: A mean period of 42 months after conventional AAA repair, the native infrarenal aortic segment elongates and dilates. Although such enlargement is statistically significant, the average increase appears to be small. However, residual aortic cuff diameter increased more than 5 mm and neck length more than 10 mm in a significant number of patients, with potentially serious implications for endovascular treatment of AAA.     

Aortic elastic properties in patients with repaired coarctation of aorta

Patients with successfully repaired coarctation of the aorta have impaired distensibility. Age at surgery as well as left ventricular mass index are factors that are related to the distensibility index.