Late Outcomes of Reintervention on the Descending Aorta After Repair of Aortic Coarctation

Abstract

Background-After repair of aortic coarctation, patients may develop restenosis, aneurysms, and pseudoaneurysms at the site of prior repair. We assessed the outcomes of late reintervention on the descending aorta after aortic coarctation repair. Methods and Results-From March 1954 to July 2008, 130 patients had operations or endovascular procedures on the descending aorta after previous coarctation repair. We excluded patients who had complex left-sided cardiac lesions or interrupted aortic arch. Mean age at reintervention was 32Ϯ24 years and 28% were female. The interval between coarctation repair and reintervention was 17Ϯ13 years. Seventy-four percent of patients had hypertension. Reasons for reintervention were restenosis (nϭ122 [94%]), aneurysm (nϭ4 [3%]), and pseudoaneurysm (nϭ4 [3%]). Ninety-five patients (73%) underwent operative procedures including an extra-anatomic conduit (nϭ41), patch repair (nϭ32), interposition graft (nϭ14), end-end anastomosis (nϭ6), and subclavian flap (nϭ2). Thirty-five patients underwent endovascular treatment (balloon dilatation, nϭ22 or stenting, nϭ13). There was no early mortality. In the surgical group, 5 patients required early reoperation for bleeding and 5 patients had early vocal cord paralysis. One patient in the endovascular group had aortic rupture at the time of intervention requiring urgent operation. Survival was 97% at 10 years. At 5 years, freedom from a second repeat procedure on the descending aorta was 96% in the surgical group and 72% in the endovascular group (PϽ0.001). Five years after reintervention, fewer patients required treatment for hypertension (57% versus 74%, PϽ0.001) and a median of 1 antihypertensive medication was prescribed compared with a median of 2 medications preintervention. Conclusions-Operative

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…In adults the pathological changes resulting from aortic coarctation may no longer be reversible. 265,266 3.6.2.1. Indications for repair.…”

“…These thresholds are based on expert opinion only, but are supported by clinical evidence suggesting that intervention before large gradients are present may confer a higher chance of reversing left ventricular dysfunction and preventing irreversible loss of aortic wall compliance. 265,266 There are two potential invasive treatment strategies, open and endovascular surgery; however, given the rarity of patients requiring invasive treatment, there are no randomized trials comparing these two options. Case series and non-randomized studies suggest marginally increased peri-operative morbidity rates with OR, and greater recurrence rates after endovascular repair.…”

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

“…In infants, however, transcatheter procedures should be considered only a temporizing step prior to eventual surgical repair in select high-risk patients who would benefit from more time before surgery. For recurrent coarctation, however, balloon angioplasty is generally felt to be superior to surgical reintervention due to its high procedural success compared to a greater incidence of surgical complications [72, 73]. …”

Extra-Anatomical Bypass: A Surgical Option for Recurrent Aortic Coarctation

“…The good general clinical conditions, the age, and the type of previous operation suggested an open repair. As reported by Brown et al [4], surgical repair of recurrent coarctation produces good and lasting results in the majority of the patients and remains the gold standard. Endovascular treatment is an adequate option in some cases, being less invasive than an open procedure and also with a lower initial cost and a shorter hospital stay.…”