Aortic Coarctation Treatment & Management

• Severe coarctation of the aorta

  • Neonates with severe coarctation of the aorta should first have their condition stabilized.
  • First, support respiratory collapse with intubation. Second, infuse prostaglandin E₁ to open the ductus arteriosus. Third, correct acidosis. Finally, provide inotropic support to improve symptoms of congestive heart failure.
• Less severe coarctation of the aorta

  • Patients presenting with less severe coarctation of the aorta beyond the neonatal period usually have chronically increased afterload and show signs of congestive heart failure. These patients should be treated with digoxin and diuretics.
  • Attempts should be made to postpone intervention, such as surgery or balloon dilatation, until the patient is hemodynamically stable.

No single technique is superior to others in minimizing the rate of restenosis. The preferred method depends on anatomy of the lesion and institutional experience.

• Indication for intervention: At present, 3 specific indications exist for intervention in patients with coarctation of the aorta.

  • Significant coarctation or recoarctation of the aorta with long-standing hypertension with or without symptoms
  • Hemodynamically significant aortic stenosis
  • Female patient contemplating pregnancy
• Types of surgery

  • In 1944, Blalock and Park performed the first experimental surgical repair of coarctation of the aorta in animals, which involved use of the left common carotid or subclavian artery to bypass the coarctation with end-to-end anastomosis.
  • Resection of the coarctation site and end-to-end anastomosis to repair coarctation was performed first on humans in 1944 by Crafoord, Nylin, Gross, and Hufagel. This is the preferred surgical method even today. In this technique, the aorta is cross-clamped above and below the obstruction, and the discrete narrowing is resected. The advantage of this procedure is that the obstructed site is completely resected. It also avoids the use of prosthetic material and maintains a functioning left subclavian artery. The disadvantages of this procedure involve the sacrifice of spinal and intercostal vessels resulting in paralysis. Also, a high rate of restenosis exists with use of continuous running suture or circumferential fibrosis. This problem is overcome by use of interrupted and absorbable sutures, which allows for improved growth of the anastomotic site.
  • Patch aortoplasty was first performed by Vossschulte in 1961 to repair coarctation of the aorta.^[3] This technique involves cutting across the obstruction and augmenting the area with a patch of prosthetic material. The advantages of this procedure include the ability to repair a long segment of coarctation; sparing of the left subclavian, intercostal, and spinal arteries; and preserving native aortic tissue to allow for growth. The disadvantage of this procedure is that it uses prosthetic material, which may gradually result in aneurysm formation.
  • Left subclavian flap angioplasty, introduced in 1966 by Waldhausen and Nahrwold, involves ligating the left subclavian artery and dividing it distally.^[4] A longitudinal incision is made from the descending aorta to the coarctation superiorly into the origin of the left subclavian artery. The subclavian artery is turned down and used to enlarge the narrowing. To prevent subclavian steal phenomena, the vertebral artery is ligated. The advantages to this procedure include preservation of native vascular tissue and avoidance of circumferential sutures, which allows for better growth of the involved area. The disadvantage to this procedure is the sacrifice of a major artery to the left arm, resulting in poor growth of that extremity.
  • Bypass graft repair bridges the ascending and descending aorta. The major disadvantage of this procedure is that prosthetic material does not grow as the child grows, and it becomes calcified and narrow with time.

Catheter-based intervention is now the preferred therapy for recurrent coarctation when the anatomy permits and necessary skills are available. Its use in native or unoperated coarctation is less well established. Treatment may be with balloon angioplasty alone or with a stent.^[5] Outcomes are good in skilled hands, but residual or recurrent coarctation with resultant hypertension and repair site aneurysms can occur. Catheter-based treatment can cause death from aortic rupture and dissection, but mortality compares favorably with surgery if coarctation is recurrent, and perhaps for initial treatment.

The immediate improvement in hypertension and morbidity were similar across all groups. Surgical therapy was associated with a low risk of restenosis and recurrence, whereas endovascular therapy had much higher incidence of restenosis and need for repeat interventions.^[6] Endovascular therapy is highly promising in elderly and frail patients with multiple comorbidities who pose a high surgical risk. Overall, long-term outcome of endovascular approaches need to be evaluated.

See Surgical Care.

As with all aortopathies and aortic valve problems, significant and prolonged isometric activities are contraindicated. The risk of dissection, even in repaired coarctation, remains significant and may be increased with isometric activity.