Coarctation of the Aorta - The Current State of Surgical and Transcatheter Therapies

Abstract

Aortic coarctation represents a distinct anatomic obstruction as blood moves from the ascending to the descending aorta and can present in a range of ages from infancy to adulthood. While it is often an isolated and discrete narrowing, it can also be seen in the more extreme scenario of severe arch hypoplasia as seen in the hypoplastic left heart syndrome or in conjunction with numerous other congenital heart defects. Since the first description of an anatomic surgical repair over sixty years ago, an evolution of both surgical and transcatheter therapies has occurred allowing clinicians to manage and treat this disease with excellent results and low morbidity and mortality. This review focuses on the current state of both transcatheter and surgical therapies, paying special attention to recent data on long-term follow-up of both approaches. Further, current thoughts will be explored about future therapeutic options that attempt to improve upon historical long-term outcomes.

Diagnosis, imaging and clinical management of aortic coarctation

“…Increased afterload on the left ventricle (LV) may lead to LV failure 4. The presence of a PDA may obscure the diagnosis of CoA until it fully constricts, as aortic flow through the PDA may bypass the juxtaductal obstruction and supply output to the lower body 8. Classical findings of CoA on clinical examination are absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (>20 mm Hg) and a murmur due to rapid blood flow across the CoA or associated lesions like BAV 8 20.…”

“…Stent implantation in young children remains controversial due to the need for frequent redilation to accommodate the growing aorta, lack of available redilatable stents, high incidence of intimal proliferation and restenosis and risk of poststent aneurysms 37. Recently, the usage of growth stents and biodegradable stents in children has been described,39 40 although long-term results of these new techniques have not been reported yet 8…”

Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy

“…Our group favors median sternotomy to address proximal arch hypoplasia and thoracotomy when hypoplasia is limited to the distal transverse arch or for patients at prohibitive risk to undergo surgical intervention with cardiopulmonary bypass [6]. Different contemporary surgical techniques and catheter-based interventions offer characteristic advantages and disadvantages, as well as a wide range of reintervention rates [7][8][9][10][11].…”

Selection of a Surgical Treatment Approach for Aortic Coarctation in Adolescents and Adults

“…However, due to the higher rates of recurrence and aneurysm formation associated with endovascular treatment, patients treated with this method require long-term follow-up. 24) In summary, CoA resection using interposition graft with CPB is recommended for spinal cord and lower body protection in adult patients. However, in adolescents, resection with end-to-end anastomosis should also be considered if continued growth is expected.…”