Endovascular treatment in a patient with aortic coarctation: case report

Abstracts

Coarctação da aorta constitui um estreitamento de origem congênita na porção inicial da aorta torácica. Tem incidência de 6 a 8% em nascidos vivos. A apresentação clínica é variada. O tratamento de escolha é o cirúrgico. Relatamos um caso de paciente do sexo feminino de 31 anos, com queixa de dor constrictiva na região cervical, dispnéia e claudicação intermitente em membros inferiores, sendo diagnosticada coarctação da aorta associada a estenose aórtica grave, que foi tratada com combinação das técnicas implantação de stent endovascular e angioplastia por balão.

Coarctação aorta; stent; angioplastia

CASE REPORT

Endovascular treatment in a patient with aortic coarctation: case report

Eugênio Carlos Almeida Tinoco; Antônio Carlos Botelho; Bruno Baião Luquini; Rafael Lima Campanha; Marcelo Nascimento; Luciana Abreu Horta; Daniela Mendonça Sueth; Felipe Montes Pena; Lincoln Rangel de Medeiros Teixeira

^{Correspondence}

ABSTRACT

Aortic coarctation is a congenital stenosis in the initial portion of the thoracic aorta. Its incidence ranges between 6–8% of liveborns. Clinical presentations are diversified. The treatment of choice is surgery. We report the case of a 31–year–old female patient with constrictive pain in the cervical region, dyspnea, and intermittent claudication of the lower limbs. She was diagnosed with aortic coarctation associated with severe aortic stenosis, which was treated using a combination of endovascular stent implantation and balloon angioplasty.

Keywords: Aortic coarctation, stent, angioplasty.

Introduction

Aortic coarctation (AC) accounts for 6–8% of liveborns with congenital cardiac disease. It is one of the most frequent diseases among obstructive anomalies of the left ventricle. When left untreated, AC has a poor prognosis, and most patients die before reaching 40 years. Surgical treatment is traditionally the chosen therapeutic choice, with good outcomes.^1–3

Stents were introduced in the 1990's as a therapy associated with balloon angioplasty, with the aim of minimizing the complications resulting from this latter procedure alone. It is a safe and efficacious technique, associated with good short– and medium–term results, reducing complication rates.^1–3 This article shows a combined treatment using the techniques mentioned above in an adult patient with AC.

Case report

A 31–year–old female patient, married, was referred to the vascular and endovascular surgery service of Hospital São José do Avaí with a diagnosis of AC. She reported constrictive pain in the cervical region of intermediate intensity started 8 months ago, with no irradiation or attenuating or aggravating factors, associated with dyspnea after moderate efforts, with current evolution to small efforts, and intermittent claudication for short distances. She presented hypertension, but was taking medication irregularly.

On cardiac auscultation, the patient had systolic murmur more audible in aortic focus (3+/6+), with irradiation for the carotid arteries. Arterial pressure was different between limbs. Vascular examination showed upper limbs with symmetrical pulses and adequate amplitude and lower limbs with impalpable pulses and normothermic and acyanotic limbs. The other systems were normal.

At admittance, she had the results of the following examinations:

1.Doppler ultrasonography: severe aortic stenosis, ectasia of the descending aorta and non–localization of the proximal segment of the descending aorta in its usual position;

2.Coronary angiography and ventriculography: aortic stenosis and AC;

3.Helical computerized tomography: AC in the proximal thoracic segment, 1.5 cm after the emergency of the left subclavian artery, with prestenotic dilatation (Figure 1).

Because the prestenotic dilatation compromises the ostium of the left subclavian and common carotid arteries, we chose to perform a right subclavian artery bypass for the left subclavian and carotid arteries. The surgery was performed using a bilateral supraclavicular incision, with dissection of corresponding vessels. As a conduit, we used an 8–mm polytetrafluoroethylene (PTFE) graft, with pretracheal and subcutaneous location of the right subclavian artery toward the left subclavian artery. For the left common carotid artery, a branch was performed based on the PTFE graft and another graft segment of the same material and size. Therefore, both vessels – left common carotid and subclavian arteries – were ligated in their origin. We then chose to use a covered stent due to the presence of significant prestenotic dilatation; at the second time point, the right common femoral artery was dissected and a 32/80 mm Zenith stent–graft was implanted and later dilated with a 32–mm balloon, a procedure that was successfully performed. However, when removing the stent–graft sheath, there was rupture of the right common femoral artery, which was promptly repaired using approach to the right common iliac artery via retroperitoneal and placement of a graft between the right common iliac artery and the right common femoral artery, using an 8–mm PTFE graft (Figure 2).

The patient was discharged on the fifth day, with symmetrical pulses and high amplitude, with no difference in arterial pressure between limbs, and was referred to the cardiology service to treat the aortic stenosis.

Discussion

AC typically consists of a lesion with localized and eccentric narrowing of the descending aorta proximal to the aortic end of the arterial channel or ligamentum arteriosum. Clinical presentation varies according to age group at time of diagnosis. A characteristic finding is based on difference in pulses and systolic arterial pressure of the upper and lower limbs, but many adults are asymptomatic. Diagnosis can be performed during routine physical examination, with the findings reported above, and there may be reduction or absence of femoral pulses.^4–6

Surgical treatment is indicated for patients with heart failure in first infancy and for children or adults with late diagnosis. Nontreatment implies future heart failure, bacterial endocarditis, stroke and heart disease.^1–7

In 1948 the first successful surgical repair of AC was performed by Craaford, with terminoterminal anastomosis. Since 1961, more than 11 technical variations have been published.⁸ The development of techniques of percutaneous intervention, including balloon angioplasty and, more recently, implantation of endovascular stents have increased the possibilities of minimally invasive treatment of the disease.⁹ Indications for use of covered stent, expandable or self–expandable balloons are critical obstruction, defined as minimal diameter at the AC level < 3 mm at angiography associated with aortic atresia, patent arterial channel, degenerative changes of the aortic wall, age higher than 30–40 years, formation of aneurysm after implantation of conventional stents, acutely detected or in the segment, and presence of circumferential fracture in graft previously implanted in the aorta.^1–9

Some authors recommend dilatation of the affected segment before stent implantation, whereas others suggest the opposite. However, in some cases, the difficulty in dilating the stenosed segment increases the risk of inappropriate stent expansion, making it insufficient, which requires its surgical removal.⁷

Balloon angioplasty is a safe and effective alternative for the treatment of AC and reflects a 93.7% success rate, with 1.8% complication rate, related to patient's age and anatomical site of the lesion.¹⁰ The main short–term complications are hypertension and recurrent or residual coarctation; in the long term, aortic aneurysm.⁶ Regarding use of stents, the reports on immediate and medium–term segment are encouraging. Initial results show partial or complete resolution of the pressure gradient in most patients, being better than those obtained with dilatation using balloon alone. Mortality rate is lower than 1–2% and main complications include large vascular dissections, aortic rupture during stent release, stent displacement or fracture and bleeding with or without formation of hematoma at the access site.¹

We conclude that surgical repair has always been the procedure of choice for AC, improving the natural history of the disease and the control of hypertension. Desire to reduce morbidity and mortality rates associated with the surgical procedure has motivated the endovascular therapy for the disease. Balloon angioplasty was developed as an alternative to the surgical treatment, in which, despite satisfactory initial outcomes, there was always the possibility of recurrent stenoses in medium– and long–term. After vascular stents were introduced, it is likely to have a lower possibility of recurrent stenosis. Covered stents have been used in the treatment of AC, preventing formation of aneurysms or dissections.

References

Manuscript received October 14, 2006, accepted January 8, 2007.

• 1. Neves J, Fraga V, Silva R, et al. Uso de stents no tratamento da coarctação da aorta. Rev Bras Cardiol Invas. 2005;13:153-66.
• 2. Kreutzer RC, Rozenbaum JC, Solsona CE, et al. Resultados quierúrgicos em coarctación de la aorta con anastomosis terminoterminal ampliada. Rev Arg Cardiol. 2003;71:93-101.
• 3. Benson L, McLaughlin PR. Coarctation of the aorta. In: Freedom R, Yoo SJ, Mikailian H, Williams WG, eds. The natural and modifical history of congenital heart disease. New York: Blackwell; 2004. p. 251-75.
• 4. Freedom RM, Mawson JB, Yoo SJ, Benson LN. Coarctation of the aorta. In: Freedom RM, Mawson JB, Yoo SJ, Benson LN, eds. Congenital heart disease. Textbook of angiography. Armonk, NY: Futura; 1997. p. 899-921.
• 5. Koch VH, Furusawa E, Haber J, Foronda G, Okay Y. Utilização da monitorização ambulatorial de pressão arterial no diagnóstico e no tratamento da coarctação da aorta. J Bras Nefrol. 2000;22:209-13.
• 6. Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. Second of two parts. N Engl J Med. 2000;342:334-42.
• 7. Alcibar J, Pena N, Onate A, Gochi R, Barrenechea JI. Stent implantation in a adult with coarctation of the aorta in the presence of advanced secondary heart failure. Tex Heart Inst J. 1999;26:143-7.
• 8. Lorier G, Wender O, Kalil RAK, et al. Coartação de aorta em crianças até um ano. Análise de 20 anos de experiência. Arq Bras Cardiol. 2005;85:51-6.
• 9. Tostes J, Ferreira R, Baptista C, Anjos R. Deiscência da aorta após colocação de stent resolução percutânea imediata. Rev Port Cardiol. 2006;25:121-4.
• 10. Munayer Calderon J, Zabal Cerdeira C, Ledesma Velazco M, et al. Balloon angioplasty in aortic coarctation: a multicentric study in México. Arch Cardiol Mex. 2002;72:20-8.

Publication Dates

• Publication in this collection
  19 July 2007
• Date of issue
  Mar 2007

History

• Received
  14 Oct 2006
• Accepted
  08 Jan 2007