SHA24/055003

BALLOON EXPANDABLE STENTS FOR COARCTATION OF THE AORTA (COA) INITIAL RESULTS AND SHORT TERM FOLLOW UP

Ismail Al Abri Suad Aamer, Mansour AlJoufan, Fadel AlFadley, Ahmed AlOmrani King Faisal Specialist Hospital and Research Center Heart Center Riyadh, Saudi Arabia

INTRODUCTION •

Balloon expandable stents used for treatment of congenital heart diseases (CHD) since 1989 .

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Intravascular stents do not interfere with normal growth, can be implanted and further dilated*

* Grifika RG et al, Am Heart J. 1993 Oct;126(4):979-84

INTRODUCTION • •

Using balloon-expandable stents gained acceptance over the years as treatment option for COA. Multiple studies showed efficacy and safety of stent therapy for both native and recoarcation post balloon angioplasty or surgical repair✼

✼ Suárez et al Am Heart J, 129 (1995), pp. 1002–1008

PURPOSE •

To determine the efficacy and safety of balloonexpandable stents as a treatment for COA.

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Report our initial results and intermediate term follow up.

METHODS • Retrospective analysis of all patients under went stent dilation for COA – between January 1999 to January 2012 – cardiac catheterization, hemodynamic and angiographic data reviwed – patient charts, blood pressure measurements and medications – ECHO data

METHODS •

Cardiac catheterization Technique – Femoral vessels access performed for the procedure and angiography at the COA were obtained pre and post stent implantation • Preferred LFA , R-carotid cut down in 1 pt • RFA ( if accessed used for continues monitoring) • RFV • extra-precautions for arterial access: ultrasound -Doppler used for access assistant

METHODS • Cardiac catheterization Technique – Right heart catheterization – Heparin anticoagulation – Retrograde Pig tail catheter in ascending aorta for angiography – Pressure gradients pre and post interventions were obtained – Retrograde floppy tip stiff exchange wire was placed preferably in right subclavian artery for positioning of long sheath and interventions

METHODS Catheterization Technique • Pressure gradients and angiographic measurements were obtained.

• Balloon size determined by proximal normal vessel diameter.

• Balloon type was dependent on physician preference , vessel diameter.

METHODS

• COA was pre-dilated if narrowest diameter will not allow long sheath passage. • Pre balloon dilation was used earlier in our experience prior to covered stent availability to test vessel compliance.

METHODS • Peak systolic gradient and vessel diameter and appearance were re-measured post intervention • Depending on type of COA native or post surgical – If residual stenosis in post surgical COA was noted by angiography or pressure gradient >20mmHg re-inflation was repeated using a larger or high pressure balloon – Re-Cath and intervention was scheduled for native tight COA after initial intervention.

RESULTS • 25 stents in 25 patients • Age : 9 – 45 yrs (median 16 yrs) • Weight: 32 to 89 (median 59 kg )

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Stent types

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Palmaz stent = 7 CP covered stent = 17 Atrium covered stent =1 (61mm long COA)

RESULTS • Native CoA : 9 (36%) - one patient was 4 month pregnantsymptomatic - Abnormal placental blood flow.

• RE-CoA 16/25 (64%) • surgical or balloon patients

- 1 pt post balloon dilation with aneurysm

Case # 1Native COA

Case # 1Native COA

Case # 1Native COA , 11 months later

Case # 2 Post Balloon • 50 yrs old lady know to have COA – Post balloon dilation at age 30 yrs.

– Followed with small aneurysm 4mm – For the past 2 yrs progression noticed and prior to intervention measured 30mm

Case # 2 Post Balloon • CP covered stent 4.5cm • Mounted over 16mm BIB balloon • RV pacing technique used to minimize displacement since no waist present

Case # 2 Post Stent

RESULTS •

Follow up mean of 24 months.

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Re-dilatation in 7/25 (28%) patients to accommodate somatic growth .

RESULTS

RESULTS

RESULTS

RESULTS •

Complications:

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No dissection or aneurysm formation.

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Minor local bleeding from puncture site controlled by pressure.

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Ne evidence of stent fracture on CXR.

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No loss of femoral or pedal pulses bilaterally.

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One patient went for heart transplantation for progressive cardiomyopathy, diagnosed prior to COA intervention.

RESULTS Medications •

12 patients pre-intervention were on 1 – 3 antihypertensive medications.

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Post stent 8/12 patient were on anti-hypertensive medications.

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All patients were maintained on aspirin for at least 6 months post procedure.

FOLLOW UP BP

Most patients have normal blood pressure but some are on medications

CONCLUSIONS • The use of balloon-expandable stents for treatment of COA is safe and effective.

• This procedure is evolving to be the treatment of choice for adolescents and adults with COA. • Long term follow up of these patients needed, and multicenter registry is warranted.

• Special attention to use those stents which could be further expanded to match the increase in somatic growth.

THANK YOU

BALLOON EXPANDABLE STENTS FOR COARCTATION OF THE AORTA (COA) INITIAL RESULTS AND SHORT TERM FOLLOW UP Ismail Al Abri Suad Aamer, Mansour AlJoufan, Fadel AlFadley, Ahmed AlOmrani

Heart Center King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia