SHA24/077002

DIFFICULT COARCTATION STENTING Prof AHMET ÇELEBİ MD Dr Siyami Ersek Hospital for Cardiology and Cardiovascular Surgery Department of Pediatric Cardiology, İstanbul, Turkey

GHA1 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Complex or Difficult COA 

Subatretic COA; technical difficulty; passing through firm stenosis/

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İ sthmus atresia: perforation of atretic membrane, aneurysm and rupture

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Turner syndrome; risk of aneurysm and rupture

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Very short segment just beneath the LSA; LSA occlusion, stent migration

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Very long segment COA; spinal artery occlusion, rupture, multiple stent

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COA with PDA; may not cover entirely the PDA, residual shunt

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COA with aneurysm; may not cover the whole aneurysm, stent migration

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Transverse arch hipoplasia; risk of protrusion to head and neck vessels

1. Butera G, et al. Covered stents in patients with complex aortic coarctations. Am Heart J 2007;154:795-800.

2. Holzer RJ et al, Cheatam JP. Stenting complex aortic arch obstructions. Cathr Cardiovasc Interv 2008 15;71:375-82

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Subatretic CoA 

Inability to pass with a catheter through the firm stenosis or

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Complete occlusion occurs when the catheter passing through,

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Always smaller than the size of the long sheath

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If it is possible to cross the stenosis retrograde by the guide-wire 

Angiogram should be performed as distal holes of the pigtail catheter below the lesion

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Pre-dilation with smaller balloons should be performed

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Covered stent must be used

If it is not possible to cross from retrograde approach

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Radial, brachial or axillary artery puncture and antegrade approach GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Subatretic COA;

retrograde pass, angiogram, predilation and covered stent implantation 4

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Subatretic COA

antegrade angiogram, retrograde crossing of the coarctation with the guidance of the antegrade guide-wire, predilation and stent implantation 6

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Subatretic COA

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Tips and trics in subatretic COA 

The advantages of radial artery puncture when it is not possible to cross the COA from femoral artery 

It is easier to pass through the COA since the guide-wire is the same direction with the blood flow

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Antegrade guide-wire can be used for guidance to pass by retrograde wire

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Interruption (or isthmus atresia) can be eliminated with proximal angiography

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Length of the interrupted or coarcted segment may be revealed by simultaneous contrast injections at both sides (proximal and distal)

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Tips and trics in subatretic COA 

If unable to pass through the COA with a coronary balloon, it can be snared from the femoral artery and pulled through. Then predilation can be performed.

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After pre-dilation, it would be easy to advance the long sheath.

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Then the procedure is performed similar to the standard stenting procedure in COA.

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

İsthmus atresia /membraneous interruption 

There is no luminal continuity between the isthmus and the descending aorta, usually separated by a membrane

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Distal aorta is supplied by collateral arteries

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The distance between the isthmus and DAO has to be short that can be perforated safely

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Perforation can be performed by 

Stiff end of the guide-wires or RF wires

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Predilation after perforation should be done gradually

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Covered stent must be used definitely

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

İsthmus atresia

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Turner syndrome and COA 

Aortic dissection after stent dilatation for coarctation of the aorta: a case report and literature review.Varma C, Benson LN, Butany J, McLaughlin PR. Catheter Cardiovasc Interv. 2003 Aug;59(4):528-35.

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Ruptured aortic dissecting aneurysm in Turner's syndrome: a case report and review of literature. Hirose H, Amano A, Takahashi A, Nagano N, Kohmoto T. Ann Thorac Cardiovasc Surg. 2000 Aug;6(4):275-80.

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Aortic dissection and Turner's syndrome: case report and review of the literature. Bordeleau L, Cwinn A, Turek M, Barron-Klauninger K, Victor G. J Emerg Med. 1998 Jul-Aug;16(4):593-6.

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Turner syndrome and COA

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Very close to the LSCA

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Long segment COA and PDA

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

COA associated with PDA

12 years old boy, COA associated with small PDA, 28 mm covered CP stent on 12 mm, 27

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

COA associated with PDA

9 years old girl ; severe COA with a large PDA, 28 mm covered stent on 14 mm balloon 28

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

COA associated with PDA

a mild COA and large PDA, 34 mm stent on 16 mm balloon implanted 29

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

There was still shunt through the duct, What was the problem?

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

20 mm Thyshak balloon was inlated at the distal part of the implanted stent 31

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

There was still residual shunt, the PTFE covering the stent might slipped out? what could we do?

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

We crossed the PDA with a guide-wire antegradely from the pulmonary artery side showing the wire was not inside the stent, so PTFE did not slipped out 33

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Redilatation of the distal part with a larger (23 mm) Thyshak balloon was performed 34

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

No shunt 35

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Native COA with aneurysm

4 years old girl with 19 kg in weight native COA with aneurysm; 28 mm in length covered stent on 10 mm Z med balloon 36

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Both COA and aneurysm improved after covered stent implantation

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Native COA with aneurysm

27 years old female, 45 mm covered stent on a 16 mm balloon was implanted 38

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Aneurysm after balloon angioplasty

Seven years old boy, aneurysm with mild re-COA after balloon angioplasty, 28 mm length covered stent on 11 mm balloon was implanted 40

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

The stent moved to the abdominal aorta immediately after implantation.

What can we do?

Leave it there? or to do something for reposition?

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

COA with aneurysm 

Covered stents must be used

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Stent should be long enough to cover entire aneurysm and COA.

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If one stent can not cover the whole lesion, two stents using telescopic method may be necessary

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The diameter of the balloon, that stent will be mounted on, may be slightly oversized to prevent migration (1-2 mm more than next normal-unaffected vessel) in mild COAs 43

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Aortic arch obstructions 

Available treatment modalities for complex aortic arch obstructions include surgery, balloon angioplasty and stent implantation.

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Many of these lesions, if not severe, are often left untreated because of a reluctance to expose a patient to major CPB surgery.

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Aortic arch obstructions are not discrete in most, usually tend to be recoil after balloon angioplasty.

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That is why, stent implantation may be a good alternative in the treatment of aortic arch obstructions

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Aortic arch obstructions 

70 LAO projection is better than others in revealing anatomy of arch

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The balloon diameter the stent mounted on should be 1-2 mm more than the largest diameter of next unaffected transverse arch

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Rapid ventricular pacing during balloon inflation is recommended to place the stent in desired position exactly

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Open cell and bare stents are recommended to avoid jailing

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

9 years old girl, operated for interrupted aortic arch, there was hypoplasia at proximal arch with a 26 mmHg gradient.

Bare stent implanted when rapid ventricular pacing performing 46

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Angiographic improvement after stent implantation Pressure gradient 26 mmHg ďƒ 2 mmHg 47

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

22 years old young men, operated for COA in infancy, 45 mmHg pressure gradient at distal aortic arch, Bare CP stent implanted when rapid ventricular pacing 48

GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Angiographic improvement and pressure gradient reduction was achived 45 mmHg ďƒ 7 mmHg

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

Conclusion ď ˝

Nowadays, percutaneous treatment of COAs with stent implantation has been preferred choice in older children, adolescents and adults.

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After covered stents has come into clinical usage and increased experience, percutaneous treatment of complex COAs including sub-atretic, atretic, associated with PDA or aneurysm and complex aortic arch obstructions have been possible.

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GHA 10th/SHA 24th Joint Scientific Conference, Feb 13-16, 2013, Riyadh

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Thanks for your attention