Coarctation of the Aorta Treatment & Management
- Author: P Syamasundar Rao, MD; Chief Editor: Stuart Berger, MD more...
Early presentation of coarctation of the aorta (CoA)
Note the following:
Treatment in patients with congestive heart failure (CHF) includes the use of diuretics and inotropic drugs.
Prostaglandin E1 (0.05-0.15 mcg/kg/min) is infused intravenously to open the ductus arteriosus.
Ventilatory assistance is provided to patients with markedly increased work of breathing.
Infusion of inotropic drugs (dopamine, dobutamine, epinephrine) is useful when ventricular dysfunction is present, especially with hypotension.
A Foley catheter is inserted to monitor renal perfusion and urine output.
ABGs are tested to monitor acidosis.
An umbilical artery catheter may be placed in neonates to assess the response to prostaglandin infusion with regard to improving lower-body blood flow.
Patients stabilized by the above interventions are better candidates for surgical or catheter intervention.
In the presence of associated defects, the significance of coarctation on the clinical course of the patient should be assessed with echo-Doppler and/or catheterization and angiographic studies. If the coarctation has a significantly adverse effect on the physiology of the associated defects, and consequently the clinical status, the coarctation should be initially relieved with surgery or balloon angioplasty and the patient reassessed with regard to need for intervention for the associated defects. Based on the authors' experience and that of others, the aortic obstruction is usually a major contributing factor for the symptomatology, and relief of the obstruction may postpone or avert the need for additional surgical intervention for the associated cardiac defects. [37, 38]
Late presentation of coarctation of the aorta
Treatment of hypertension
Preoperative hypertension can be effectively treated using beta-blockers. The goal should be to reduce upper extremity hypertension, but remember that vigorous attempts to achieve normal upper extremity blood pressure (BP) may result in inadequate lower-body perfusion. Beta-blocker therapy prior to surgery may reduce the severity of postoperative hypertension, although most patients with preoperative hypertension require at least transient postoperative therapy. Remember that relieving the aortic obstruction promptly rather that attempting to treat hypertension with antihypertensive medications is better.
Postoperative hypertension can be treated short-term with vasodilators, such as sodium nitroprusside, and intravenous beta-blockers, such as esmolol. When longer-term antihypertensive therapy is required, beta-blockers may be continued, and if no residual arch obstruction exists, ACE inhibitors or angiotensin II antagonists (pediatric dosing not established for angiotensin II antagonists) may be added if hypertension persists despite beta-blocker therapy.
Guidelines regarding beta-adrenergic receptor blockers have been established.
One study concluded that data is not sufficient to discourage or recommend the use of beta-blockers in children with CHF.
Evaluate associated abnormalities
Associated abnormalities include aortic stenosis, subaortic stenosis, and mitral valve disease.
Evaluate adequacy of collateral blood vessels
The adequacy of the collateral blood vessels is used to assess the safety of surgical intervention.
Significant hypertension or congestive heart failure (CHF) is an indication for intervention. Surgical relief of the aortic obstruction and catheter interventional techniques (balloon angioplasty and stents) are available alternatives. Symptomatic neonates and infants should undergo urgent intervention soon after the infant is stabilized. Asymptomatic infants, children, adolescents, and adults should undergo the procedure electively. If neither hypertension nor heart failure is present, elective surgical or balloon therapy in children aged 2-5 years is suggested. Waiting beyond age 5 years for surgery or balloon therapy to relieve aortic obstruction is not advisable because of the evidence of residual hypertension if intervention is performed after age 5 years.
Since the introduction of surgical correction by Crafoord and Nylin (1945) and by Gross and Hufnagel (1945) in the early 1940s, surgical therapy has been the preferred treatment for aortic coarctation. Various surgical techniques have been used to treat patients with coarctation of the aorta, namely, resection and end-to-end anastomosis, patch aortoplasty, left subclavian flap aortoplasty, and tubular bypass grafts. The techniques are occasionally combined or modified to fit the individual patient's anatomy.
For instance, a reverse left subclavian flap aortoplasty may be used, turning the left subclavian artery as a patch back toward the left carotid artery to enlarge an area of transverse arch hypoplasia. In addition, an extended end-to-end repair may be used, in which the segment of descending aorta is beveled and brought up to the underside of the transverse arch to enlarge areas of transverse arch hypoplasia. The exact technique used varies depending on the patient's age at presentation, size, associated abnormalities, and arch anatomy. A surgical approach from a median sternotomy, rather than the classic left lateral thoracotomy, is used commonly in complex arch repairs.
In a review of 1337 patients undergoing repair of coarctation in infancy, the following findings were reported :
Subclavian flap aortoplasty was performed in 763 patients (57%). Resection in end-to-end anastomosis was used in 406 patients (30%), and patch aortoplasty was used in 133 patients (9.9%). In addition, 20 patients underwent placement of an interposition graft or bypass graft.
In the series, the mortality risk was highest in neonates in whom surgery was performed during the first week of life, whereas only 8 of 279 infants aged 3 months to 1 year who underwent surgery died. Mortality associated with surgery was also higher in smaller infants, particularly in infants who weighed less than 3 kg and infants with associated cardiac anomalies.
The presence of a ventricular septal defect (VSD) with or without minor associated anomalies increased the risk of death from 0.9% (no anomalies) to 6.8% (with VSD). Complex associated anomalies, such as a single ventricle or transposition of the great arteries, greatly increased the mortality rate to 16.6%. Similarly, the surgical mortality rate in neonates who required surgery early was high at 45%. Urgent surgery may be required if the patent ductus arteriosus cannot be opened and the patient continues to have poor urine output and acidosis.
In the presence of a hemodynamically significant VSD, historically, placement of a pulmonary artery band was performed to limit pulmonary blood flow at the time of left thoracotomy for coarctation repair. Current surgical approach uses a single-stage repair of the coarctation and VSD, usually through a sternotomy, even in the small neonate.
In severe transverse arch hypoplasia that results in significant residual obstruction following coarctation repair, an ascending-to-descending aortic conduit may be placed. This is usually a less favorable approach because the patient may be obligated to undergo subsequent surgeries for conduit replacement.
In most centers, associated defects may be addressed at the time of surgery for coarctation by proceeding with a median sternotomy to repair lesions such as mitral stenosis or subaortic obstruction or to accomplish left ventricular (LV) outflow tract enlargement. Occasionally, the adequacy of the LV volume is called into question, and the patient may require a modified Norwood repair. Decision making about this issue is addressed in Hypoplastic Left Heart Syndrome. However, note that hypoplasia of the left heart structures, particularly the LV, associated with isolated CoA usually improves following relief of aortic obstruction.
Repair of coarctation in the asymptomatic child or adolescent is usually undertaken on an elective basis after assessment of associated anomalies and appropriate preoperative evaluation. The timing of intervention in the otherwise asymptomatic patient has been debated. The rationale for delaying surgery until age 3-5 years has been based on the size of the aorta in childhood relative to the anticipated adult size. Because significant obstruction occurs when the diameter of the aorta is reduced by 50% or more, delaying surgery until age 3-5 years allows the aorta to be larger than half the anticipated adult size at operation, theoretically reducing the risk of significant residual obstruction in the event that the surgical repair site does not grow over time. However, issues of hypertension, progressive LV hypertrophy, or LV dysfunction mandate earlier repair.
Improvements in surgical techniques have led most cardiologists to recommend surgery at the time of diagnosis, especially in patients with hypertension. In patients with only mild obstruction, especially those diagnosed in the first year of life, surgery may safely be delayed and the patient monitored for worsening obstruction or development of hypertension prior to recommending surgery.
Pseudo-coarctation of the aorta refers to abnormal tortuosity of the aorta that does not result in significant obstruction or hypertension and is noted for the lack of development of collateral vessels. This abnormality does not require surgical intervention.
Surgical repair of coarctation of the aorta is accomplished in children and adolescents with generally good results and low mortality. Of 824 patients who underwent coarctation repair in childhood, 431 (52%) underwent end-to-end anastomosis, whereas patch aortoplasty was performed in 214 patients (26%) and only 109 patients (13%) underwent subclavian flap aortoplasty. Death occurred in only 6 of 824 patients for a total mortality rate of 0.73%. The surgical era of this cohort does not reflect the current surgical strategy for aggressive complete arch repair or the aorta and all associated lesions. The trend is toward the less frequent use of patch aortoplasty because of concerns regarding the development of aortic aneurysm at the site of repair.[44, 45, 46, 47]
Operative mortality rates in neonates and infants are high (4-50%), whereas the operative mortality rates in older children are low (0-5%). The high mortality in the young infant appears to be related to the condition of the infant at the time of surgery and the associated defects.
Significant recoarctation (6-33% in infants, 0-18% in older children)[37, 48] ; formation of aneurysms in all types of coarctation repair, particularly well-documented following prosthetic patch angioplasty[48, 49] ; development of paraplegia[20, 21, 50] ; paradoxical hypertension[22, 23, 24] ; and vascular complications related to subclavian flap repair[51, 52, 53, 54, 55] continue to be problems.
In a study examining long-term results of surgery by MRI of 247 patients aged 33.0 ± 12.8 years, restenosis (mild in 31% and significant in 9%) and dilatation of the aortic segment (13%), with discrete aneurysm at the repair site in 9%, was observed. However, antihypertensive therapy was required, which controlled the blood pressure in 93% patients. Mortality rate was low, but significantly higher than age-matched healthy controls.
Late hypertension continues to be a problem.
Despite these problems, surgical repair is considered by many to be the therapeutic option of choice in the treatment of aortic coarctation. Some groups of workers, including the authors' group, consider balloon angioplasty the initial therapy of choice and reserve surgical intervention for the following coarctations:
Coarctations that involve the long segment of the aorta
Coarctations that are completely or almost completely occluded so that no catheter or guide wire can be passed across the coarcted segment
Coarctations that are associated with a large patent ductus arteriosus and ventricular septal defect that requires prompt surgical intervention for the primary cardiac problem.
Gruntzig's technique of balloon angioplasty was adopted by Sos et al (1979), Singer et al (1982), and Sperling et al (1983) for enlargement of coarcted aortic segments in a postmortem specimen, postsurgical recoarctation, and native coarctation, respectively. Other cardiologists then used this technique to treat native coarctation of the aorta. Numerous investigators reported their experiences with balloon angioplasty of native aortic coarctations. However, the use of balloon angioplasty for treatment of native aortic coarctation is controversial.[1, 58] This section describes the technique and the results of balloon angioplasty.
Technique[15, 48, 59]
Cardiac catheterization and selective cineangiography are performed to confirm the clinical diagnosis, to exclude other cardiac defects, and to assess suitability for balloon angioplasty. Once balloon angioplasty is chosen, a 4F-6F multi-A2 (Cordis) catheter is introduced into the femoral artery percutaneously and is positioned across the aortic coarctation. Then, a 0.021-0.035 in J-tipped guide wire is passed through the catheter into the ascending aorta and the tip of the wire positioned in the ascending aorta. A 4F-7F balloon angioplasty catheter is then positioned across the aortic coarctation. The balloon is inflated with diluted contrast material to approximately 3-5 atm of pressure or higher, depending on the manufacture's recommendations.
Monitoring pressure of inflation via any of the commercially available pressure gauges is recommended. The balloon is inflated for 5 seconds. A total of 2-4 balloon inflations are performed 5 minutes apart. Aortography and measurement of pressure gradients across the coarctation of the aorta are performed. The heart rate, systemic pressure, and cardiac index are recorded prior to and 15 minutes after balloon dilatation to ensure that the change in pressure gradient is related to balloon dilation rather than changes in patient status.
The author generally performs this procedure with the patient under conscious sedation, whereas others advocate general anesthesia. Most cardiologists use percutaneous femoral artery approach for cardiac catheterization and balloon angioplasty. Occasionally, femoral artery cutdown or left axillary artery cutdown is necessary if the percutaneous approach is unsuccessful. The authors and others have used a transumbilical approach in neonates in an attempt to avoid the use of the femoral arteries.[15, 60] In patients in whom the aorta can be entered from the right ventricle (either directly in patients with transposition of the great arteries or double outlet right ventricle or indirectly through a ventricular septal defect), balloon angioplasty may be performed transvenously.
The size of the balloon chosen for angioplasty is 2 or more times the size of the coarcted segment, but no larger than the size of the descending aorta at the level of the diaphragm, as measured from a frozen video recording. The authors usually choose a balloon that is midway between the size of the aortic isthmus (or transverse aortic arch) and the size of the descending aorta at the level of diaphragm. If the relief of obstruction is not adequate (pressure gradient reduction to < 20 mm Hg and angiographic improvement), a balloon as large as the diameter of the descending aortic at the level of diaphragm is chosen for additional dilatation.[48, 61]
The authors usually give 100 U of heparin per kilogram prior to introducing the balloon-angioplasty catheter. Activated clotting times should be measured every 30 minutes and maintained between 200 and 250 seconds. The heparin effect is neither reversed nor continued after the procedure. Administering adequate doses of heparin to prevent thromboembolism is important.[48, 62]
The balloon inflation pressure should be monitored and attempts should be made not to exceed that stated by the manufacturer; this is to prevent balloon rupture and its adverse effects.[37, 48]
A catheter or a guide wire must not be manipulated over the site of a freshly dilated coarctation of the aorta. A guide wire should always be left in place across the coarctation segment, and all angiographic and balloon-dilatation catheters should be exchanged over the guide wire.
Balloon size should be carefully chosen to prevent aneurysm.
Use of large-caliber angioplasty catheters may result in significant femoral artery compromise. Availability of balloon catheters that can be introduced through 4F sheaths appears to reduce the femoral artery injury. Even these may injure the femoral artery in the young infant; in such situations, the authors use 3F sheaths through which the more recently available balloon dilatation catheters (eg, Mini-Tyshak [Braun] catheters) can be introduced, which may further reduce such complications.
Despite an initial report of poor results, subsequent experience with balloon angioplasty appears encouraging and has been detailed elsewhere.[32, 37, 48, 64, 65, 66] A reduction of pressure gradient across the coarctation and an increase in the size of the coarcted segment have been observed. The collateral vessels promptly diminish. The femoral pulses, which had been either absent or markedly reduced and delayed (when compared with brachial pulses) become palpable with increased pulse volume after balloon angioplasty.
The infants who were in heart failure improved, as did their hypertension. The infants who were ventilator dependent could be weaned off of the ventilator support and were extubated. Most infants (beyond the neonate period) and children are discharged from the hospital within 24 hours after balloon angioplasty. None of the authors' patients required immediate surgical intervention.
Intermediate-term follow-up results
Several investigators have reported 1-year to 2-year follow-up results, and these studies suggest continued improvement. From the authors' study, 60 patients (58 catheterization, 2 clinical) were observed; the residual gradients 14 ± 11 (mean ± standard deviation [SD]) months following angioplasty remained low at 16 ± 15 mm Hg. These gradients continue to be lower (P < .001) than those prior to angioplasty (46 ± 17 mm Hg) and are slightly higher (P < .05) than the gradients (11 ± 9 mm Hg) immediately following angioplasty. The angiographically measured coarctation segment remained wide. Only a modest increase is found (11 ± 9 vs 16 ± 15 mm Hg; P < .05) in peak gradients for the group as a whole, but, when individual patient values are examined, 15 (25%) of the 60 patients had evidence of recoarctation, defined as a peak-to-peak systolic pressure gradient in excess of 20 mm Hg.
The incidence of recoarctation is higher in neonates (5 [83%] of 6; P < .01) and infants (7 [39%] of 18; P =.011) than in children (3 [8%] of 36). Ten of these children underwent repeat balloon angioplasty, and their gradients were reduced (P < .001) from 39 ± 11 mm Hg to 10 ± 6 mm Hg. Early in the authors' experience, 2 patients underwent surgical resection with good results. The final 3 children had no discrete narrowing and had no hypertension; therefore, no intervention was recommended. Aneurysms developed in 3 (5%) of 58 patients who underwent follow-up angiography; one of these patients required surgical excision of the aneurysm and the other 2 are observed clinically.
Similar high recoarctation rates were documented by our group[68, 69] in neonates and infants less than three months of age, but balloon angioplasty provided successful and effective palliation in 92% infants.
Long-term follow-up results
Only scant data can be found on long-term follow-up after balloon angioplasty of native coarctation. Despite recoarctation and aneurysms, some requiring repeat intervention at intermediate-term follow-up, the long-term follow-up results (5-9 y) appear encouraging, in that minimal incidence of late recoarctation and no late aneurysm formation was found.[58, 70, 71]
Event-free survival curves following initial balloon angioplasty suggest that the event-free rates are better (P < .001) in children than in infants and neonates. In most children, the arm blood pressure remained normal and the blood pressure–determined gradient between arms and legs remained low.
Applicability in adult patients
Although balloon angioplasty of aortic coarctation has most frequently been used in neonates, infants, and children, it can also be used in adult patients.
Lababidi et al (1984) were the first to apply this technique in a 27-year-old man, resulting in reduction of peak systolic pressure gradient across the coarctation (from 70 to 15 mm Hg), angiographic improvement, and reduced hypertension (190/124 mm Hg vs 130/80 mm Hg). They subsequently reported their experience with balloon dilatation of native coarctation in 8 consecutive adults, aged 19-30 years (25 ± 5 y). The systolic pressure gradient across the coarctation was reduced from 48 ± 19 mm Hg to 7 ± 5 mm Hg. The size of the coarcted segment increased from 6.8 ± 2.2 mm to 15.2 ± 5 mm. No complications were encountered. Clinical and echo-Doppler follow-up one year after the procedure revealed good results, with no more than 15 mm Hg peak systolic blood pressure difference between the arms and the legs (measured by cuff). They concluded that results in young adults are similar to those observed inchildren,balloonangioplastyshouldbeconsideredasanoptiontosurgicalintervention, and follow-up studies (>1 y) are required.
Other reports followed, which revealed equally good results. Based on a review of these studies, aortic perforation during the procedure and aneurysmal formation at follow-up are also apparent in adults. In addition, intimal dissection that persisted at 6-month follow-up was seen in one patient. Therefore, (1) avoiding manipulation to the tips of the catheters and guide wires in the region of freshly dilated coarctation, (2) choosing an appropriate-sized balloon (no larger that the diameter of the descending aorta at the level of the diaphragm), and (3) monitoring for the development of aneurysms and, if found, closely following the progression of aneurysms with repeated angiography or MRI are prudent guidelines. Twenty-year follow-up for discrete coarctations appear encouraging.
Surgery compared with balloon therapy
Scant data are available to compare surgical intervention with balloon angioplasty. In an attempt to compare the safety and efficacy of balloon angioplasty with surgical correction of aortic coarctation, the authors scrutinized 49 papers (published from 1980-1991) that reported on results of surgery in infants younger than 1 year and 9 papers that compared the results of balloon angioplasty in children.[37, 48] These data showed that recoarctation rates are similar, whereas the mortality rates are slightly higher in the surgical than the balloon angioplasty series. Similar comparison of results in children older than 1 year showed identical results.
Shaddy and associates (1993) prospectively randomized 36 patients aged 3-10 years to undergo either balloon angioplasty (20 patients) or surgery (16 patients) and found similar immediate pressure gradient relief in both groups. The risks of aneurysm formation and restenosis were higher in the balloon angioplasty group, whereas risks of neurologic complications were higher in the surgical group. They concluded that balloon angioplasty in coarctation of the aorta may provide an effective initial alternative to surgery in children beyond infancy and suggested that further follow-up is needed to evaluate the long-term risks of aneurysms following angioplasty.
The senior author compared the efficacy and safety of balloon angioplasty with those of surgical correction in infants younger than 3 months. Data on 29 infants who underwent intervention for aortic coarctation from 1982-1992 were examined. Fourteen infants underwent surgical repair, and 15 underwent balloon angioplasty. The data indicated that the degree of relief of aortic obstruction and the frequency with which reintervention is needed are similar in both groups. However, balloon angioplasty carries lower morbidity rates and complications than with surgical therapy. Based on these data, the we suggested that balloon angioplasty may be an acceptable alternative to surgery in the treatment of symptomatic aortic coarctation in infants younger than 3 months.
Shim and colleagues (1997) compared hospital charges and found lower charges for patients who underwent balloon therapy compared to surgery.
Complications such as paraplegia[20, 21, 50] and paradoxical hypertension[22, 23] are seen following surgical repair, although such complications are rare and, if present, very mild and inconsequential following balloon angioplasty. Aneurysms following balloon angioplasty[48, 77, 78] are of concern and need further study, although such aneurysms are also seen with surgical repair. The femoral artery occlusion rate following balloon angioplasty may be higher than that seen with surgical therapy. However, vascular complications can occur in the left upper limb following coarctation repair with subclavian flap aortoplasty; these complications include gangrene, reduction in the length and muscle mass of upper arm and forearm, and abnormal Doppler blood flow velocities in brachial arteries, suggesting potential for symptoms of ischemia.[51, 52, 53, 54]
Cowley et al (2005) compared long-term (mean, 10-11 y) results of balloon angioplasty with those of surgery for patients with native aortic coarctation who were randomized at entry into the study and found similar resting blood pressures, residual gradients across the coarctation, exercise performance, aortic arch anatomy based on MRI angiography, and reintervention rates. However, the incidence of aneurysms and greater arm-to-leg blood pressure difference during exercise was higher in the balloon group than in the surgery group.
Cowley et al suggested that surgery is preferable to balloon angioplasty in the management of aortic coarctation in children. Although randomization is a virtue of the study, the study involves only 36 children, with only 21 (58%) returning for reevaluation. Furthermore, other studies in which a larger number of balloon angioplasty procedures were evaluated at long-term follow-up revealed 5% aneurysm formation. Aneurysm formation was also detected in surgical patients. Consequently, a multi-institutional randomized study with a larger number of subjects is in order to resolve the issues brought out by this paper.
Rodés-Cabau et al (2007) compared transcatheter and surgical treatment and concluded that immediate results were similar, but with reduced morbidity and duration of hospitalization with transcatheter intervention. However, angioplasty was associated with a higher rate of reintervention and aneurysm formation.
Wong and associates (2008) used decision analysis to compare preferences for balloon angioplasty versus surgery and concluded that balloon angioplasty is preferred over surgery as the initial treatment for native aortic coarctation in children; however, this type of decision analysis approach was questioned.
Based on the above review, the effectiveness of balloon angioplasty appears to be comparable with that of surgery; the mortality rates are similar (and are probably related to the associated cardiac defects, not related to type of intervention performed), and morbidity and complication rates are lower with balloon angioplasty than with surgical therapy. Balloon angioplasty may be an effective alternative to surgery for the relief of aortic coarctation.
Residual and recurrent obstructions cannot be easily distinguished, and the term recoarctation may be used to describe both entities. Recoarctation is defined as a peak-to-peak systole pressure gradient in excess of 20 mm Hg with or without angiographically demonstrable narrowing. Recoarctation following both surgical correction and balloon angioplasty has been described.
Recoarctation following surgery does not depend on the type of surgical repair[44, 48] ; it has been observed following resection with end-to-end anastomosis, subclavian flap angioplasty, prosthetic patch repair, subclavian artery turn-down procedure, and interposition tube grafts. The reported incidence of recoarctation has varied depending on the study. The average recoarctations rates were 11-17% in neonates and infants younger than 1 year and 5.6% in children older than 1 year. In a large cohort of patients studied by Pinzon et al (1991), recoarctation occurred in 23%. Recent reports demonstrate similar recoarctation rates.[83, 84] The younger the child at surgery, the higher the chance for recoarctation.
Although no consensus has been reached in regard to the method of intervention (surgery vs balloon angioplasty) for native aortic coarctation, both cardiologists and cardiovascular surgeons generally agree that balloon angioplasty is the treatment of choice for postsurgical aortic coarctations.[48, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94] The immediate and follow-up results of balloon angioplasty for postsurgical recoarctation are essentially similar to those of native coarctations and have been reviewed in detail elsewhere.
Restenosis following balloon angioplasty also appears to be age dependent; the younger the child, the greater the chance for recoarctation. The authors[58, 64] and others recommend repeat balloon dilatations in such cases, whereas others prefer surgical intervention.
The technique of balloon angioplasty for the management of both postsurgical and post–balloon angioplasty recoarctations is similar to that described above for native coarctation.
Based on an extensive review of the literature and personal experience with the procedure for more than 25 years, some generalizations with regard to balloon therapy may be made, as follows.
Children older than 1 year and adults with discrete native coarctation are candidates for balloon dilatation. Most cardiologists agree on this issue. Long-segment coarctations or those associated with significant isthmic hypoplasia may be candidates for stent placement, especially in adolescents and adults.
Recurrent coarctation following previous balloon angioplasty may be treated with repeat balloon angioplasty; others prefer surgery. If the recoarcted segment is long, surgical treatment in younger children and stents in adolescents and adults seem appropriate.
Treatment of coarctation in neonates and infants is perhaps the most controversial issue. Many cardiologists prefer surgical intervention, whereas a few cardiologists may opt for balloon angioplasty.
Balloon angioplasty is useful in the treatment of extremely ill neonates and infants with severe coarctation; in this subset of patients, the balloon angioplasty has a significant advantage over a surgical approach.
Most cardiologists and surgeons agree that balloon angioplasty is the treatment of choice for postsurgical recoarctations.
Vascular stenotic lesions can be opened with balloon angioplasty, but, because of the elastic recoil of the vessel wall, the vessel lumen may return to the predilation size following withdrawal of the balloon catheter. Such recoil and vascular dissection following balloon dilatation can be circumvented with implantation of endovascular stents. Dotter (1969), in the late 1960s, suggested this concept and implanted spiral coil-spring prostheses into the experimentally produced peripheral artery stenotic lesions. The stent concept and technology were dormant until the early 1980s, when the balloon-expandable and self-expanding stents were designed and used. Initially, stents were used in the treatment of peripheral arterial disease and coronary artery stenotic lesions in adults. The technique was then extended to the treatment of other stenotic vessels, including aortic coarctation.[61, 97]
Despite reasonably good short-term and long-term results of balloon angioplasty, some problems remain, including restenosis, probability of aortic rupture, formation of aneurysms, and inability to effectively treat long-segment tubular narrowing. Because of these and other reasons, endovascular stenting of aortic coarctation has gained acceptance over the last decade.[60, 91, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119]
The following are perceived advantages of stents over balloon angioplasty:
The ability to expand tubular long-segment coarctation, hypoplastic isthmus, and the distal transverse aortic arch
The ability to increase the coarcted segment diameter independently of the intimal tear
The ability to decrease the probability of restenosis
The ability to prevent dissection of the torn intimal flap by facilitating apposition of the intima against the media
The ability to prevent aneurysms because of the support of the weakened aortic wall with the stent and neointima
O'Laughlin et al (1991) were the first to use a stent for the treatment of aortic coarctation, although the results in a 12-year-old child were marginal. Subsequently, numerous others reported the use of a stent in aortic coarctation with encouraging results.[61, 64, 91, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119]
Because of growth issues and the need for large sheaths for implantation, most cardiologists limit stent usage to adolescents and adults. The following are indications for using stent:
Associated hypoplasia of the isthmus or aortic arch
Tortuous coarctation with malalignment of the proximal and distal aortic segment
Recurrent aortic coarctation or an aneurysm following prior surgical or balloon therapy
The procedure may be performed under conscious sedation or under general anesthesia. Cardiac catheterization is performed to confirm the clinical and echocardiographic diagnosis and to exclude other cardiac defects. Pressure gradients across the coarctation and selective cineangiography in multiple angiographic projections are initially performed to demonstrate the stenotic lesions.
The following measurements are made: (1) the diameter of the stenotic lesion, (2) the diameter of the aorta proximal and distal to the obstructive segment, and (3) the length of the vessel that can be stented. All the measurements are made in 2 orthogonal views and averaged. Foreshortening of the vessel length is taken into account based on the anatomy. These measurements are used in the selection of expanded diameter and length of the stent. Heparin (100 U/kg) is administered, and activated clotting times are monitored and maintained between 200-250 seconds by giving additional doses of heparin, as needed.
An end-hole catheter (5F-6F multi-A2) is positioned across the coarctation with the help of a soft-tipped 0.035-in Bentson guide wire. The guide wire and catheter are advanced into the ascending aorta. The tip of the catheter may also be placed in the right or left subclavian arteries, depending on the location and angulation of the coarcted segment. The catheter is left in place, and the guide wire is removed and replaced with either an extra-stiff exchange-length 0.035-in Amplatz or a super-stiff, short tip, Amplatz guide wire. The catheter is then removed.
If the approach to the lesion is tortuous or difficult to reach, the authors select a 0.038-in super-stiff Amplatz wire. An appropriate-sized long blue Cook sheath with a multipurpose curve and a radiopaque marker at the tip is introduced over the stiff wire. Once the tip of the sheath is past the site intended to be stented, the dilator is removed and the sheath flushed. Sometimes, the dilator has to be withdrawn slightly to position the tip of the sheath at the desired location.
The selection of the sheath diameter obviously depends on the size of the stent delivery catheter. The authors have always attempted to select a balloon delivery system that would allow the smallest possible sheath diameter. Initially, when other workers were using Meditech PE-MT balloon catheters, which required 11F sheaths, the authors were using Olbert balloon catheters, which can be introduced through 8F or 9F sheaths for mounting the stent. Subsequently, the authors have used Bridge stents, which can also be delivered via 8F or 9F sheaths. Most recently, the authors used IntraStent DoubleStrut stents and Palmaz Genesis. The latter stents are mounted on balloon-in-balloon (BIB) catheters. The size of the sheath used is 1F larger than the sheath size needed for the BIB catheter.
The selected stent is hand crimped onto a BIB catheter; the authors use a sterile umbilical tape to further crimp the stent onto the balloon.
The balloon catheter, with the stent mounted on it, is advanced over the stiff guide wire but within the sheath and positioned across the coarctation segment. The tip of the sheath is withdrawn distal to the aortic coarctation based on bony landmarks. Contrast is also injected via the side arm of the blue Cook sheath, and the position of the stent is adjusted as necessary. Some cardiologists place catheters into the ascending aorta via trans-septal route or from radial artery for angiography during stent placement. Although this may provide better visualization, the authors do not routinely recommend it to avoid additional time in the catheterization laboratory and morbidity associated with such additional procedures.
In cases in which the BIB catheter is used, the inner balloon is inflated at the manufacturer's recommended pressure and the position of the stent adjusted, if needed, followed by inflation of the outer balloon, thus implanting the stent. The balloon catheter is then advanced slightly, centering the balloon across the proximal end of the stent, and the outer balloon is re-inflated to ensure apposition of the stent against the vessel walls. The balloon catheter is then centered over the distal end of the stent. This is performed by advancing the tip of the sheath over the deflated balloon into the stent to prevent inadvertent displacement of the stent. The outer balloon is then re-inflated to ensure apposition of the distal stent against the vessel walls.
If the outer balloon diameter is not as large as the desired diameter of the stent, additional balloon expansion with larger diameter balloons is performed. The author always tries to avoid this step by using an outer balloon of the BIB catheter at the desired diameter. Following the removal of the balloon catheter, a multitrack catheter is positioned over the wire, and pressure pullback tracings and angiography are performed to assess the results of stent implantation.
The effect of heparin is not reversed, and no additional doses of heparin are administered. Intravenous cefazolin 25 mg/kg/dose (maximum of 1 g) is started in the catheterization laboratory, and 2 additional doses are administered at 6- to 8-hour intervals. Aspirin in platelet-inhibiting doses (5-10 mg/kg/d) is started on the day following the procedure and continued for 6 weeks. Use of heparin overnight on the day of procedure and more potent platelet-inhibiting drugs or anticoagulation with warfarin (Coumadin) have been undertaken in the past. At present, the data do not indicate the need for intensive anticoagulation. Aspirin alone appears to suffice. However, more potent platelet-inhibiting drugs, such as clopidogrel, may be used in adults.
To avoid potential balloon rupture, the tip of the guide wire is placed in the right subclavian artery instead of the ascending aorta, which is the usual practice for balloon angioplasty. Try not to position the stent across the origins of left common carotid artery and left subclavian artery. However, on occasion, avoiding the subclavian artery is impossible. In such situations, the authors have carefully traversed the stent cells (in between the struts) with a soft guide wire followed by a multi-A2 catheter. The stent cell is then dilated with an angioplasty balloon of a diameter equal to that of the proximal left subclavian artery; uncompromised flow to the left subclavian artery was found in these patients. Predilation of the coarcted segment with balloon angioplasty prior to stenting is no longer recommended.
The reduction of peak systolic pressure gradients and an increase in the diameter of the coarcted segment have been demonstrated following stent implantation.[60, 73, 88, 99, 100, 101, 102, 103, 104, 105, 106, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 123] Stenting was found to be effective in postsurgical and postballoon recoarctations, as well as in native coarctations. The ratio of diameters of coarcted segment to the descending aorta at the level of the diaphragm increased to unity in many patients who undergo aortic stenting. Improvement in the size of hypoplastic isthmus or transverse aortic arch and exclusion of the aneurysm, if present, also occurred after stent placement.
In the first series of 10 patients published by Suarez de Lezo et al in 1995, the peak systolic pressure gradient across the coarctation decreased from 43 ± 12 to 2 ± 3 mm Hg (P < .001). The ratio of isthmus/descending aorta increased from 0.65 ± 0.14 to 1 ± 0.08 following the procedure. Similar results have been reported subsequently by other investigators.[68, 73]
Vessel disruption, displacement of stent,[100, 106, 108, 113, 124] stent fracture, and aneurysms[104, 106] are rare but do occur. Balloon rupture that results in inadequate stent expansion and stent migration has been reported but may be prevented by avoiding curvature of the balloon or stent assembly, the use of newer stents with less injurious ends, and the use of BIB catheters.[99, 113]
Because of the large size of the sheath required, loss of pulse and bleeding from a puncture site may occur. Use of vascular closure devices may help circumvent this problem. Rare complications included myocardial infarction and retroperitoneal hemorrhage.
Most studies had only a short-term and incomplete follow-up in a limited number of patients. However, a few studies examined results of more than 20 patients at a mean follow-up of 2 years or longer.[106, 109, 112, 113, 123] The pressure gradients across the coarctation site (blood pressure, Doppler, or catheterization) remained low, and systemic hypertension decreased both in degree and frequency with the consequent decrease in the need for antihypertensive medications. No evidence for recoarctation, aneurysmal formation, or stent fracture or displacement was observed in most studies, although no systematic or complete follow-up was achieved in most studies. In some studies new aneurysms (in 6% of patients), stent fractures and jailed or partially covered brachiocephalic vessels were seen.
Residual or recurrent obstruction was present in a few patients, and, in these, successful redilatation with larger balloons was accomplished. Detailed angiographic studies by Suarez de Lezo et al (1999) revealed no detectable neointimal proliferation in 75% of patients; in the remaining patients, focal neointimal ridge formation was observed at the ends of the stent, causing minimal restenosis. Segmental analysis of the aorta revealed an increase in nonstented segments of the aorta, consistent with normal growth. Two young patients (7%) developed small new aneurysms that were obliterated by coil placement following angiographic detection. However, the overall follow-up results were encouraging.
Note the following:
Stent therapy appears to be an attractive method for the treatment of recurrent coarctation or aneurysm formation following prior surgical or balloon intervention and for long-segment hypoplasia. Most cardiologists use stents in adolescents and adults, although a few have advocated their use in younger children. [106, 127, 128] The selection of the type of stent and the type of balloon catheter used for stent deployment appears to be evolving. Balloon-expandable stents are preferred over self-expandable stents. However, some workers used self-expandable stents successfully. 
The use of a BIB catheter for stent delivery appears to be gaining momentum in an attempt to prevent balloon ruptures and perforation of other cardiovascular structures.
Positioning the guide wire into the right or left subclavian artery may avoid excessive curvature and, thus, may prevent balloon rupture.
Flexible instead of rigid Palmaz stents are being used.
Selected stent diameter at implantation should be at least twice the diameter of the narrowest aortic segment to prevent stent displacement during implantation.
The issues related to placement of the stent across the mouths of the arch vessel still need to be resolved.
Relief of obstruction both short-term and at follow-up with a low incidence of major complications is well demonstrated in several studies.
Meticulous attention to the technique and adoption of new technology, when it becomes available, may further reduce the incidence of complications.
Recoarctation rate at follow-up appears to be low. Re-expansion of the stent to treat residual or recoarctation and growth-related narrowing appears feasible, safe, and effective, although this is based on limited experience. 
The few studies that have compared balloon angioplasty with stents suggest that stents may be more effective. [117, 131, 132] Similar comparison between surgery and stents indicate stenting for native coarctation of the aorta is an effective alternative to surgical intervention in older children. [133, 134]
Based on the available data, stenting aortic coarctation appears to be the preferred alternative to surgical or balloon therapy in adolescents and young adults.
Experience in the use of covered stents to manage aortic coarctation is limited.[126, 135, 136, 137, 138, 139, 140, 141] Different types of stents to treat aortic coarctation have been used and include Jostent grafts, C-P stents, and AneuRx. Although these stents are available outside the United States, none are yet approved for clinical use by the US Food and Drug Administration (FDA). However, customizing and off-label use of available endoluminal grafts are feasible, when necessary. The indications for intervention are similar to those used for balloon angioplasty and deployment of the standard stent.
The indications for use of covered stents include postangioplasty aneurysm, tortuous aortic arch and isthmus, associated patent ductus arteriosus, prior surgical conduit, Takayasu arteritis, and extremely narrow (subatretic) coarcted segment. When the assessed risk for development of aneurysm or dissection is high, a covered stent should be used. The results of the limited use of covered stents appear to be good.[126, 135, 136, 137, 138, 139, 140, 141] Some of the stents can be expanded to only an 18-mm diameter. In addition, the stent shortens when expanded to larger diameters. Use of covered stents has another disadvantage in that the vessels that arise from the aorta are blocked.
Aortic rupture remains an important, though an infrequent, complication following primary stenting for aortic coarctation. Covered stents have been used to reduce this risk. However, aortic rupture has been reported even with covered stents.
Renarrowing of covered stents has been reported, and data in limited number of patients suggest Covered Cheatham-Platinum stents can redilated.
A comparison between bare and covered Cheatham-platinum stents in a randomized clinical trial of 120 patients, aged 23.60 ± 10.99 years at a follow-up duration of 31.1 ± 19.2 months revealed a higher prevalence of recoarctation in bare metal stents and greater occurrence of pseudoaneurysm in covered stents; neither of these achieved statistical significance, however. Number of subjects with normal blood pressure increased in both groups. Collapse and infolding of the covered stents can occur with the use of covered stents, requiring placement of additional stents.[146, 96]
Based on the currently available data, the covered stents may be useful in highly selected patients with aortic coarctation.
Comparison of different treatment modalities
In a multi-institutional study of 350 patients, Forbes et al compared surgery, balloon angioplasty, and stent implantation for treatment of native aortic coarctation and demonstrated improvement in all 3 groups both acutely and at follow-up. However, the stent group had fewer complications (compared with surgical and balloon angioplasty patients), shorter hospitalization (compared with surgical patients), and lower coarctation gradients at follow-up (compared with balloon patients), but had higher “planned” reintervention (compared with surgical and balloon patients).
The study is flawed in that there were a disproportionally large number of patients in the stent group (217, stent; 61, balloon angioplasty; 72, surgery), small number of patients followed (35.7%, with less than 75% of these patients having had imaging studies), and presumed noninclusion of all eligible patients into the study. Significant age and weight differences (P < .001) between study groups were found, although the authors attempted to address this issue by including an analysis of a subgroup of patients aged 6-12 years. Equally disturbing is the nonrandomized nature of the study. The authors, however, correctly concluded that these results should be interpreted with caution, which could be amended to “great” caution.
Instead of debating which treatment is better, it is prudent to tailor the treatment depending on the age of the patient and the pathology (anatomy) of the coarctation and the surrounding region. Most cardiologists prefer surgical intervention for treatment of neonatal and infant (< 1 y) coarctations. Children older than 1 year with discrete native coarctation are candidates for balloon dilatation. If the coarctation segment is long, surgical treatment in younger children and stents in adolescents and adults would seem appropriate.
Causes of recoarctation following balloon angioplasty have been extensively investigated,[82, 148, 149] and factors predictive of recoarctation have been identified and include young age and severely narrowed isthmus and coarcted segment. More recently, studies of biophysical characteristics of the coarcted segment revealed less recoil in the subset of recoarctation patients, implying that the elastic properties of the aortic wall are not preserved. This may be related to cystic medial necrosis[151, 152] or to extension of the ductal tissue into the aortic wall.[152, 153, 154]
However, the true cellular pathophysiologic mechanisms responsible for recoarctation have not been identified. Once they are identified, appropriate treatment algorithms to prevent recoarctation could be developed to address the pathophysiology. Until such time, keeping coarcted segments open with stents is an attractive option. Unfortunately, the stents, which are metallic, do not grow with the child and cannot be used routinely in neonates and infants.
Biodegradable stents[155, 156] may offer a solution; these stents keep the coarcted aortic segment open for a 3-month to 6-month period, after which the stents dissolve. By then, the ratio of the normal aortic tissue to abnormal tissue may be in favor of the infant, thus preventing recurrence of significant narrowing. However, this hypothesis should be tested in appropriate animal models and stent delivery systems miniaturized so that they can be used in neonates and young infants. Similarly growth stents may allow re-dilatation at a later date.
Summary of treatment
At initial presentation, if cardiac failure or hypertension is the presenting problem, it should be addressed to stabilize the patient. Subsequently, the aortic obstruction should be relieved. The available options include surgical and catheter interventional procedures; the latter procedures include balloon angioplasty and bare or covered stents.
In general, surgical intervention in neonates and young infants (extremely ill babies with poor left ventricular function may benefit from balloon angioplasty), balloon angioplasty in children, and stent deployment in adolescents and adults appear to be appropriate options. Of course, the anatomy of the coarcted aortic segment and the aortic arch would greatly influence the method of therapy in a given patient.
In infants who present early with CHF, stabilization in the ICU may be required prior to surgical intervention.
In premature infants, consultation with a neonatologist may be required to manage associated diseases related to prematurity, such as hyaline membrane disease.
Consultation with a geneticist may be indicated if Turner syndrome or other genetic conditions are suspected.
Consultation with a nephrologist may be needed for assistance in treating patients with hypertension in preoperative or postoperative acute renal failure.
Older patients may be initially referred to specialists prior to the diagnosis of coarctation of the aorta. Referral to a hypertension clinic may lead to the diagnosis of coarctation of the aorta by the nephrologist. Patients who undergo evaluation for suspected genetic syndromes may be referred to the cardiologist for evaluation because of previously undiagnosed coarctation.
Complications of coarctation of the aorta, such as intracranial hemorrhage or endocarditis, may require consultation with a neurosurgeon or infectious disease specialist, respectively.
Persistent hypertension has been shown to increase the incidence of coronary artery disease (CAD); therefore, periodically examine patients who have undergone coarctation of the aorta repair for hypertension and recommend a healthy low-fat, and perhaps, low-salt diet.
Measure cholesterol levels and intervene pharmacologically in older patients as indicated, with a total cholesterol goal of less than 200 g/dL.
Patients with persistent hypertension may require varying degrees of salt restriction.
Emphasize dietary counseling and avoidance of obesity and smoking.
Patients with coarctation of the aorta and hypertension who are awaiting surgical repair should limit heavy isometric exercises to a degree commensurate with the degree of hypertension.
Generally, the duration of hypertension after coarctation of the aorta repair is related in part to the duration of hypertension prior to diagnosis and repair of coarctation. Patients who undergo repair of coarctation in infancy usually remain normotensive in the absence of significant residual arch obstruction and require no specific activity restrictions or limitations. With growth, coarctation may recur, and some patients may be normotensive at rest but have significant upper extremity hypertension provoked by exercise. Such patients who desire to participate in competitive athletics should undergo exercise stress testing prior to clearance.
Patients who undergo repair later in life and who have had a significant period of preoperative hypertension are at particular risk for sustained postoperative hypertension, which may be permanent. Restrict heavy isometric exercise and other activities in these patients, commensurate with the degree of hypertension and BP control. Use exercise testing to assess BP response to exercise as a means of delineating reasonable exercise limitations.
Rao PS. Should balloon angioplasty be used instead of surgery for native aortic coarctation?. Br Heart J. 1995 Dec. 74(6):578-9. [Medline].
Rudolph AM, Heymann MA, Spitznas U. Hemodynamic considerations in the development of narrowing of the aorta. Am J Cardiol. 1972 Oct. 30(5):514-25. [Medline].
Talner NS, Berman MA. Postnatal development of obstruction in coarctation of the aorta: role of the ductus arteriosus. Pediatrics. 1975 Oct. 56(4):562-9. [Medline].
Cassels DE. The Ductus Arteriosus. Springfield, IL: Charles C. Thomas; 1973. 161.
Skoda J. Demonstration eines Falles Ven Obliteration de Aorta. Wochenblatt Zeischrift de kaiserlichen-Konighiche Gesellschaft der Aerttze Zur Wien. 1995. 1:710-720.
Goldblatt H, Kahn JR, Hanzal RF. Studies on experimental hypertension: IX. The effect on blood pressure of constriction of the abdominal aorta above and below the site of origin of both main renal arteries. J Exp Med. 1939 Apr 30. 69(5):649-74. [Medline].
Scott HW Jr, Bahnson HT. Evidence for a renal factor in the hypertension of experimental coarctation of the aorta. Surgery. 1951 Jul. 30(1):206-17. [Medline].
Scott HW Jr, Collins HA, Langa AM, Olsen NS. Additional observations concerning the physiology of the hypertension associated with experimental coarctation of the aorta. Surgery. 1954 Sep. 36(3):445-59. [Medline].
Alpert BS, Bain HH, Balfe JW, Kidd BS, Olley PM. Role of the renin-angiotensin-aldosterone system in hypertensive children with coarctation of the aorta. Am J Cardiol. 1979 Apr. 43(4):828-34. [Medline].
Bagby SB. Dissection of pathogenetic factors: I. Coarctation hypertension. Loggie JMH, Horan MJ, Hohn AR, et al, eds. Proceedings of the NHLBI Workshop on Juvenile Hypertension. New York, NY: Biomedical Information Corp; 1984. 253-66.
Gersony WM. Coarctation of the aorta. Adams FH, Emmanouildes GC, Riemenschneider TA, eds. Moss' Heart Disease in Infants, Children and Adolescents. 4th ed. Baltimore, MD: Williams & Wilkins; 1989. 243-55.
Cody RJ. Hormonal alterations in heart failure. Hosenpud JD, Greenberg BH, eds. Congestive Heart Failure: Pathophysiology, Diagnosis and Comprehensive Approach to Management. 2nd ed. Lippincott Williams & Wilkins: 2000. 199-212.
Nadas, AS, Fyler DC. Pediatric Cardiology. 3rd ed. Philadelphia, PA: Saunders; 1972. 683.
Keith JD, Rowe RD, Vlad P. Heart Disease in Infancy and Childhood. 3rd ed. New York, NY: Macmillan; 1978. 4-6.
Rao PS. Balloon angioplasty of native aortic coarctation. J Am Coll Cardiol. 1992 Sep. 20(3):750-1. [Medline].
Rao PS. Coarctation of the aorta. Ram CVS, ed. Secondary Forms of Hypertension; Seminars in Nephrology, Kurtzman NA, ed. Philadelphia, PA: WB Saunders; 1995. 15(2): 81-105.
Bobby JJ, Emami JM, Farmer RD, Newman CG. Operative survival and 40 year follow up of surgical repair of aortic coarctation. Br Heart J. 1991 May. 65(5):271-6. [Medline].
Oliver JM, Gallego P, Gonzalez AE, et al. Pulmonary hypertension in young adults with repaired coarctation of the aorta: an unrecognised factor associated with premature mortality and heart failure. Int J Cardiol. 2014 Jun 15. 174(2):324-9. [Medline].
Campbell M. Natural history of coarctation of the aorta. Br Heart J. 1970 Sep. 32(5):633-40. [Medline].
Crawford FA, Sade RB. Spinal cord injury associated with hyperthermia during aortic coarctation repair. J Thorac Cardiovasc Surg. 1984. 87:610-6.
Brewer LA 3rd, Fosburg RG, Mulder GA, Verska JJ. Spinal cord complications following surgery for coarctation of the aorta. A study of 66 cases. J Thorac Cardiovasc Surg. 1972 Sep. 64(3):368-81. [Medline].
Sealy WC, Harris JS, Young WG Jr, Callaway HA Jr. Paradoxical hypertension following resection of coarctation of aorta. Surgery. 1957 Jul. 42(1):135-47. [Medline].
Ho EC, Moss AJ. The syndrome of "mesenteric arteritis" following surgical repair of aortic coarctation. Report of nine cases and review of the literature. Pediatrics. 1972 Jan. 49(1):40-5. [Medline].
Tabbutt S, Nicolson SC, Adamson PC, Zhang X, Hoffman ML, Wells W. The safety, efficacy, and pharmacokinetics of esmolol for blood pressure control immediately after repair of coarctation of the aorta in infants and children: a multicenter, double-blind, randomized trial. J Thorac Cardiovasc Surg. 2008 Aug. 136(2):321-8. [Medline].
Strafford MA, Griffiths SP, Gersony WM. Coarctation of the aorta: a study in delayed detection. Pediatrics. 1982 Feb. 69(2):159-63. [Medline].
Thoele DG, Muster AJ, Paul MH. Recognition of coarctation of the aorta. A continuing challenge for the primary care physician. Am J Dis Child. 1987 Nov. 141(11):1201-4. [Medline].
Norton JB Jr. Coarctation of the Aorta. Moller JH, ed. Surgery of Congenital Heart Disease: Pediatric Cardiac Care Consortium. Armonk, NY: Futura Publishing Co; 1984-1995. 143-57.
Salahuddin N, Wilson AD, Rao PS. An unusual presentation of coarctation of the aorta in infancy: role of balloon angioplasty in the critically ill infant. Am Heart J. 1991 Dec. 122(6):1772-5. [Medline].
Ing FF, Starc TJ, Griffiths SP, Gersony WM. Early diagnosis of coarctation of the aorta in children: a continuing dilemma. Pediatrics. 1996 Sep. 98(3 Pt 1):378-82. [Medline].
Nora JJ. Multifactorial inheritance hypothesis for the etiology of congenital heart diseases. The genetic-environmental interaction. Circulation. 1968 Sep. 38(3):604-17. [Medline].
Saidi AS, Bezold LI, Altman CA, Ayres NA, Bricker JT. Outcome of pregnancy following intervention for coarctation of the aorta. Am J Cardiol. 1998 Sep 15. 82(6):786-8. [Medline].
Rao PS, Carey P. Doppler ultrasound in the prediction of pressure gradients across aortic coarctation. Am Heart J. 1989 Aug. 118(2):299-307. [Medline].
Silvilairat S, Cetta F, Biliciler-Denktas G, Ammash NM, Cabalka AK, Hagler DJ. Abdominal aortic pulsed wave Doppler patterns reliably reflect clinical severity in patients with coarctation of the aorta. Congenit Heart Dis. 2008 Nov-Dec. 3(6):422-30. [Medline].
Mohiaddin RH, Kilner PJ, Rees S, Longmore DB. Magnetic resonance volume flow and jet velocity mapping in aortic coarctation. J Am Coll Cardiol. 1993 Nov 1. 22(5):1515-21. [Medline].
Pitlick PT, Anthony CL, Moore P, Shifrin RY, Rubin GD. Three-dimensional visualization of recurrent coarctation of the aorta by electron-beam tomography and MRI. Circulation. 1999 Jun 15. 99(23):3086-7. [Medline].
Goubergrits L, Riesenkampff E, Yevtushenko P, et al. MRI-based computational fluid dynamics for diagnosis and treatment prediction: clinical validation study in patients with coarctation of aorta. J Magn Reson Imaging. 2015 Apr. 41(4):909-16. [Medline].
Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctation. Ann Thorac Surg. 1991 Sep. 52(3):621-31. [Medline].
Rao PS, Chopra PS, Koscik R, Smith PA, Wilson AD. Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old. J Am Coll Cardiol. 1994 May. 23(6):1479-83. [Medline].
[Guideline] Lopez-Sendon J, Swedberg K, McMurray J, et al. Expert consensus document on beta-adrenergic receptor blockers. Eur Heart J. 2004 Aug. 25(15):1341-62. [Medline].
Frobel AK, Hulpke-Wette M, Schmidt KG, Laer S. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev. 2009 Jan 21. CD007037. [Medline].
Liberthson RR, Pennington DG, Jacobs ML, Daggett WM. Coarctation of the aorta: review of 234 patients and clarification of management problems. Am J Cardiol. 1979 Apr. 43(4):835-40. [Medline].
Lacour-Gayet F, Bruniaux J, Serraf A, Chambran P, Blaysat G, Losay J. Hypoplastic transverse arch and coarctation in neonates. Surgical reconstruction of the aortic arch: a study of sixty-six patients. J Thorac Cardiovasc Surg. 1990 Dec. 100(6):808-16. [Medline].
Krauser DG, Rutkowski M, Phoon CK. Left ventricular volume after correction of isolated aortic coarctation in neonates. Am J Cardiol. 2000 Apr 1. 85(7):904-7, A10. [Medline].
Pinzon JL, Burrows PE, Benson LN, et al. Repair of coarctation of the aorta in children: postoperative morphology. Radiology. 1991 Jul. 180(1):199-203. [Medline].
Parikh SR, Hurwitz RA, Hubbard JE, Brown JW, King H, Girod DA. Preoperative and postoperative "aneurysm" associated with coarctation of the aorta. J Am Coll Cardiol. 1991 May. 17(6):1367-72. [Medline].
Parks WJ, Ngo TD, Plauth WH Jr, Bank ER, Sheppard SK, Pettigrew RI. Incidence of aneurysm formation after Dacron patch aortoplasty repair for coarctation of the aorta: long-term results and assessment utilizing magnetic resonance angiography with three-dimensional surface rendering. J Am Coll Cardiol. 1995 Jul. 26(1):266-71. [Medline].
Chiesa R, Melissano G, Civilini E, Bertoglio L, Setacci F, Baccellieri D. Giant aneurysm 25 years after patch aortoplasty for aortic coarctation. Tex Heart Inst J. 2008. 35(2):220-1. [Medline].
Rao PS. Neurologic complications following balloon angioplasty. Pediat Cardiol. 1993. 14:63-4.
Mendelsohn AM, Crowley DC, Lindauer A, Beekman RH 3rd. Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta. J Am Coll Cardiol. 1992 Aug. 20(2):381-5. [Medline].
Connolly JE. Hume Memorial lecture. Prevention of spinal cord complications in aortic surgery. Am J Surg. 1998 Aug. 176(2):92-101. [Medline].
Kittle CF, Schafer PW. Gangrene of the forearm after subclavian arterioaortostomy for coarctation of the aorta. Thorax. 1953 Dec. 8(4):319-22. [Medline].
Geiss D, Williams WG, Lindsay WK, Rowe RD. Upper extremity gangrene: a complication of subclavian artery division. Ann Thorac Surg. 1980 Nov. 30(5):487-9. [Medline].
Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late effects on the left upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg. 1983 May. 85(5):678-81. [Medline].
van Son JA, van Asten WN, van Lier HJ, Daniels O, Vincent JG, Skotnicki SH. Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy. Circulation. 1990 Mar. 81(3):996-1004. [Medline].
Maddali MM, Menon RG, Valliattu J, Maimouna HA. Left upper limb shortening following reverse flap subclavian artery angioplasty. Asian Cardiovasc Thorac Ann. 2008 Aug. 16(4):346-7. [Medline].
Chen SS, Dimopoulos K, Alonso-Gonzalez R, et al. Prevalence and prognostic implication of restenosis or dilatation at the aortic coarctation repair site assessed by cardiovascular MRI in adult patients late after coarctation repair. Int J Cardiol. 2014 May 1. 173(2):209-15. [Medline].
O'Sullivan J. Late hypertension in patients with repaired aortic coarctation. Curr Hypertens Rep. 2014 Mar. 16(3):421. [Medline].
Rao PS, Galal O, Smith PA, Wilson AD. Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol. 1996 Feb. 27(2):462-70. [Medline].
Rao PS. Balloon angioplasty for coarctation of the aorta in infancy. J Pediatr. 1987 May. 110(5):713-8. [Medline].
Rao PS. Current status of balloon angioplasty for neonatal and infant aortic coarctation. Progress Pediat Cardiol. 2001. 14(1):35-44.
Rao PS. Demographic features of tricuspid atresia. Rao PS, ed. Tricuspid Atresia. 2nd ed. Mount Kisco, NY: Futura; 1992. 23-37.
Treacy EP, Duncan WJ, Tyrrell MJ, Lowry NJ. Neurological complications of balloon angioplasty in children. Pediatr Cardiol. 1991 Apr. 12(2):98-101. [Medline].
Lock JE, Bass JL, Amplatz K, Fuhrman BP, Castaneda-Zuniga W. Balloon dilation angioplasty of aortic coarctations in infants and children. Circulation. 1983 Jul. 68(1):109-16. [Medline].
Rao PS, Galal O, Wilson AD. Feasibility and effectiveness of repeated balloon dilatation of restenosed congenital obstructions after previous balloon valvuloplasty/angioplasty. Am Heart J. 1996 Aug. 132(2 Pt 1):403-7. [Medline].
Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. Am Heart J. 1990 Dec. 120(6 Pt 1):1315-20. [Medline].
Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol. 1990 Mar 15. 65(11):790-2. [Medline].
Rao PS. Should balloon angioplasty be used as a treatment of choice for native aortic coarctations?. J Invasive Cardiol. 1996 Sep. 8(7):301-13. [Medline].
Rao PS. Stents in the management of congenital heart disease in pediatric and adult patients. Indian Heart J. 2001 Nov-Dec. 53(6):714-30. [Medline].
Rao PS, Jureidini SB, Balfour IC, et al. Severe aortic coarctation in infants less than 3 months: successful palliation by balloon angioplasty. J Intervent Cardiol. 2003. 15:203-208.
Lababidi Z. Percutaneous balloon coarctation angioplasty: long-term results. J Interv Cardiol. 1992 Mar. 5(1):57-62. [Medline].
Rao PS. Long-term follow-up results after balloon dilatation of pulmonic stenosis, aortic stenosis, and coarctation of the aorta: a review. Prog Cardiovasc Dis. 1999 Jul-Aug. 42(1):59-74. [Medline].
Attia IM, Lababidi ZA. Early results of balloon angioplasty of native aortic coarctation in young adults. Am J Cardiol. 1988 Apr 15. 61(11):930-1. [Medline].
Rao PS. Coarctation of the aorta. Curr Cardiol Rep. 2005 Nov. 7(6):425-34. [Medline].
Fawzy ME, Fathala A, Osman A, et al. Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults. Am Heart J. 2008 Nov. 156(5):910-7. [Medline].
Shaddy RE, Boucek MM, Sturtevant JE, et al. Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation. 1993 Mar. 87(3):793-9. [Medline].
Shim D, Lloyd TR, Moorehead CP, Bove EL, Mosca RS, Beekman RH 3rd. Comparison of hospital charges for balloon angioplasty and surgical repair in children with native coarctation of the aorta. Am J Cardiol. 1997 Apr 15. 79(8):1143-6. [Medline].
Marvin WJ, Mahoney LT, Rose EF. Pathologic sequelae of balloon dilation angioplasty of unoperated coarctation of the aorta in children (Abstract). J Am Coll Cardiol. 1986. 7:117A.
Cooper RS, Ritter SB, Rothe WB, Chen CK, Griepp R, Golinko RJ. Angioplasty for coarctation of the aorta: long-term results. Circulation. 1987 Mar. 75(3):600-4. [Medline].
Cowley CG, Orsmond GS, Feola P, McQuillan L, Shaddy RE. Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood. Circulation. 2005 Jun 28. 111(25):3453-6. [Medline].
Rodes-Cabau J, Miro J, Dancea A, et al. Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study. Am Heart J. 2007 Jul. 154(1):186-92. [Medline].
Ebels T, Maruszewski B, Blackstone EH. What is the preferred therapy for patients with aortic coarctation--the standard gamble and decision analysis versus real results?. Cardiol Young. 2008 Feb. 18(1):18-21. [Medline].
Rao PS. Balloon angioplasty of aortic coarctation: a review. Clin Cardiol. 1989 Nov. 12(11):618-28. [Medline].
Hager A, Schreiber C, Nutzl S, Hess J. Mortality and restenosis rate of surgical coarctation repair in infancy: a study of 191 patients. Cardiology. 2009. 112(1):36-41. [Medline].
Bacha EA. Long-term outcomes after coarctation repair in infancy. Cardiology. 2009. 112(1):35. [Medline].
Singer MI, Rowen M, Dorsey TJ. Transluminal aortic balloon angioplasty for coarctation of the aorta in the newborn. Am Heart J. 1982 Jan. 103(1):131-2. [Medline].
Kan JS, White RI Jr, Mitchell SE, Farmlett EJ, Donahoo JS, Gardner TJ. Treatment of restenosis of coarctation by percutaneous transluminal angioplasty. Circulation. 1983 Nov. 68(5):1087-94. [Medline].
Hess J, Mooyaart EL, Busch HJ, Bergstra A, Landsman ML. Percutaneous transluminal balloon angioplasty in restenosis of coarctation of the aorta. Br Heart J. 1986 May. 55(5):459-61. [Medline].
Lorber A, Ettedgui JA, Baker EJ, Jones OD, Reidy J, Tynan M. Balloon aortoplasty for recoarctation following the subclavian flap operation. Int J Cardiol. 1986 Jan. 10(1):57-63. [Medline].
Saul JP, Keane JF, Fellows KE, Lock JE. Balloon dilation angioplasty of postoperative aortic obstructions. Am J Cardiol. 1987 Apr 15. 59(9):943-8. [Medline].
Rao PS. Which aortic coarctations should we balloon-dilate?. Am Heart J. 1989 Apr. 117(4):987-9. [Medline].
Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol. 1990 Mar 15. 65(11):793-7. [Medline].
Anjos R, Qureshi SA, Rosenthal E, et al. Determinents of hemodynamic results of balloon dilation of aortic recoarctation. Am J Cardiol. 1992. 69:665-71.
Reich O, Tax P, Bartakova H, et al. Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents. Eur Heart J. 2008 Aug. 29(16):2042-8.
Yetman AT, Nykanen D, McCrindle BW, et al. Balloon angioplasty of recurrent coarctation: a 12-year review. J Am Coll Cardiol. 1997 Sep. 30(3):811-6. [Medline].
Minich LL, Beekman RH, Rocchini AP, et al. Surgical repair is safe and effective after unsuccessful balloon angioplasty of native coarctation of the aorta. J Am Coll Cardiol. 1993. 19:389-3.
Zollikofer CL, Antonucci F, Stuckmann G, Mattias P, Salomonowitz EK. Historical overview on the development and characteristics of stents and future outlooks. Cardiovasc Intervent Radiol. 1992 Sep-Oct. 15(5):272-8. [Medline].
Rao PS. Stents in treatment of aortic coarctation. J Am Coll Cardiol. 1997 Dec. 30(7):1853-5. [Medline].
O'Laughlin MP, Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation. 1991 Jun. 83(6):1923-39. [Medline].
Suarez de Lezo J, Pan M, Romero M, et al. Balloon-expandable stent repair of severe coarctation of aorta. Am Heart J. 1995 May. 129(5):1002-8. [Medline].
Rosenthal E, Qureshi SA, Tynan M. Stent implantation for aortic recoarctation. Am Heart J. 1995 Jun. 129(6):1220-1. [Medline].
Bulbul ZR, Bruckheimer E, Love JC, Fahey JT, Hellenbrand WE. Implantation of balloon-expandable stents for coarctation of the aorta: implantation data and short-term results. Cathet Cardiovasc Diagn. 1996 Sep. 39(1):36-42. [Medline].
Chander JS, Wolfe SB, Rao PS. Role of stents in the management of congenital heart disease. J Invasive Cardiol. 1996. 8:314-25.
Thanopoulos BV, Triposkiadis F, Margetakis A, Mullins CE. Long segment coarctation of the thoracic aorta: treatment with multiple balloon-expandable stent implantation. Am Heart J. 1997 Apr. 133(4):470-3. [Medline].
Ebeid MR, Prieto LR, Latson LA. Use of balloon-expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol. 1997 Dec. 30(7):1847-52. [Medline].
Suarez de Lezo J, Pan M, Romero M, et al. Immediate and follow-up findings after stent treatment for severe coarctation of aorta. Am J Cardiol. 1999 Feb 1. 83(3):400-6. [Medline].
Thanopoulos BD, Hadjinikolaou L, Konstadopoulou GN, Tsaousis GS, Triposkiadis F, Spirou P. Stent treatment for coarctation of the aorta: intermediate term follow up and technical considerations. Heart. 2000 Jul. 84(1):65-70. [Medline]. [Full Text].
Marshall AC, Perry SB, Keane JF, Lock JE. Early results and medium-term follow-up of stent implantation for mild residual or recurrent aortic coarctation. Am Heart J. 2000 Jun. 139(6):1054-60. [Medline].
Harrison DA, McLaughlin PR, Lazzam C, Connelly M, Benson LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. Heart. 2001 May. 85(5):561-6. [Medline].
Cheatham JP. Stenting of coarctation of the aorta. Catheter Cardiovasc Interv. 2001 Sep. 54(1):112-25. [Medline].
Ledesma M, Alva C, Gomez FD, et al. Results of stenting for aortic coarctation. Am J Cardiol. 2001 Aug 15. 88(4):460-2. [Medline].
Hamdan MA, Maheshwari S, Fahey JT, Hellenbrand WE. Endovascular stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol. 2001 Nov 1. 38(5):1518-23. [Medline].
Santoro G, Carminati M, Bigazzi MC, et al. Primary stenting of native aortic coarctation. Tex Heart Inst J. 2001. 28(3):226-7. [Medline].
Tyagi S, Singh S, Mukhopadhyay S, Kaul UA. Self- and balloon-expandable stent implantation for severe native coarctation of the aorta in adults. Am Heart J. 2003. 146:920-8.
Rao PS. Newer stents in the management of vascular stenosis in children. Rao PS, Kern MJ, eds. Catheter Based Devices in the Treatment of Non-coronary Cardiovascular Disease in Adults and Children. Philadelphia, PA: Lippincott, William & Wilkins; 2003. 369-378.
Pedra CA, Fontes VF, Esteves CA, et al. Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults. Catheter Cardiovasc Interv. 2005 Apr. 64(4):495-506. [Medline].
Golden AB, Hellenbrand WE. Coarctation of the aorta: stenting in children and adults. Catheter Cardiovasc Interv. 2007 Feb 1. 69(2):289-99. [Medline].
Holzer RJ, Chisolm JL, Hill SL, Cheatham JP. Stenting complex aortic arch obstructions. Catheter Cardiovasc Interv. 2008 Feb 15. 71(3):375-82. [Medline].
Dehghani P, Collins N, Benson L, Horlick E. Role of routine radial artery access during aortic coarctation interventions. Catheter Cardiovasc Interv. 2007 Oct 1. 70(4):622-3. [Medline].
Recto MR, Ing FF, Grifka RG, Nihill MR, Mullins CE. A technique to prevent newly implanted stent displacement during subsequent catheter and sheath manipulation. Catheter Cardiovasc Interv. 2000 Mar. 49(3):297-300. [Medline].
Bonhoeffer P, Piechaud JF, Stumper O, et al. The multi-track angiography catheter: a new tool for complex catheterisation in congenital heart disease. Heart. 1996 Aug. 76(2):173-7. [Medline].
Forbes TJ, Moore P, Pedra CA, et al. Intermediate follow-up following intravascular stenting for treatment of coarctation of the aorta. Catheter Cardiovasc Interv. 2007 Oct 1. 70(4):569-77. [Medline].
Amirghofran AA, Peiravian F, Borzoee M, Emaminia A, Mollazadeh R. A wandering stent in the ascending aorta. J Cardiovasc Med (Hagerstown). 2008 Sep. 9(9):969-70. [Medline].
Rohit MK, Garg PK, Talwar K. Stent fracture after stent therapy for aortic coarctation: nightmares in invasive cardiology. Indian Heart J. 2007 Jan-Feb. 59(1):77-9. [Medline].
Qureshi AM, McElhinney DB, Lock JE, Landzberg MJ, Lang P, Marshall AC. Acute and intermediate outcomes, and evaluation of injury to the aortic wall, as based on 15 years experience of implanting stents to treat aortic coarctation. Cardiol Young. 2007 Jun. 17(3):307-18. [Medline].
Schaeffler R, Kolax T, Hesse C, Peuster M. Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms. Cardiol Young. 2007 Dec. 17(6):617-22. [Medline].
Al-Ata J, Arfi AM, Hussain A, Kouatly A, Galal MO. Stent angioplasty: an effective alternative in selected infants with critical native aortic coarctation. Pediatr Cardiol. 2007 May-Jun. 28(3):183-92. [Medline].
Hijazi ZM, Fahey JT, Kleinman CS, Hellenbrand WE. Balloon angioplasty for recurrent coarctation of aorta. Immediate and long-term results. Circulation. 1991 Sep. 84(3):1150-6. [Medline].
Duke C, Rosenthal E, Qureshi SA. The efficacy and safety of stent redilatation in congenital heart disease. Heart. 2003 Aug. 89(8):905-12. [Medline].
Zabal C, Attie F, Rosas M, Buendia-Hernandez A, Garcia-Montes JA. The adult patient with native coarctation of the aorta: balloon angioplasty or primary stenting?. Heart. 2003 Jan. 89(1):77-83. [Medline].
Macdonald S, Thomas SM, Cleveland TJ, Gaines PA. Angioplasty or stenting in adult coarctation of the aorta? A retrospective single center analysis over a decade. Cardiovasc Intervent Radiol. 2003 Jul-Aug. 26(4):357-64. [Medline].
Anagnostopoulos-Tzifa A. Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol. 2007 Sep-Oct. 48(5):290-5. [Medline].
Weber HS, Cyran SE. Endovascular stenting for native coarctation of the aorta is an effective alternative to surgical intervention in older children. Congenit Heart Dis. 2008 Jan. 3(1):54-9. [Medline].
Gunn J, Cleveland T, Gaines P. Covered stent to treat co-existent coarctation and aneurysm of the aorta in a young man. Heart. 1999 Sep. 82(3):351. [Medline].
de Giovanni JV. Covered stents in the treatment of aortic coarctation. J Interv Cardiol. 2001 Apr. 14(2):187-90. [Medline].
Forbes T, Matisoff D, Dysart J, Aggarwal S. Treatment of coexistent coarctation and aneurysm of the aorta with covered stent in a pediatric patient. Pediatr Cardiol. 2003 May-Jun. 24(3):289-91. [Medline].
Ewert P, Peters B, Nagdyman N, Miera O, Kuhne T, Berger F. Early and mid-term results with the Growth Stent--a possible concept for transcatheter treatment of aortic coarctation from infancy to adulthood by stent implantation?. Catheter Cardiovasc Interv. 2008 Jan 1. 71(1):120-6. [Medline].
Duggal B, Radhakrishnan S, Mathur A, Khurana P, Shrivastava S. Covered stents deployed for coarctation of aorta with aneurysm. Indian Heart J. 2005 Jul-Aug. 57(4):346-9. [Medline].
Butera G, Piazza L, Chessa M, et al. Covered stents in patients with complex aortic coarctations. Am Heart J. 2007 Oct. 154(4):795-800. [Medline].
Eicken A, Kaemmerer H, Ewert P. Treatment of aortic isthmus atresia with a covered stent. Catheter Cardiovasc Interv. 2008 Nov 15. 72(6):844-6. [Medline].
Preventza O, Wheatley GH 3rd, Williams J, Ramaiah VG, Rodriguez-Lopez JA, Diethrich EB. Novel endovascular repair of the small thoracic aorta: customizing off-the-shelf endoluminal grafts. J Card Surg. 2007 Sep-Oct. 22(5):434-5. [Medline].
Collins N, Mahadevan V, Horlick E. Aortic rupture following a covered stent for coarctation: delayed recognition. Catheter Cardiovasc Interv. 2006 Oct. 68(4):653-5. [Medline].
Butera G, Gaio G, Carminati M. Redilation of e-PTFE covered CP stents. Catheter Cardiovasc Interv. 2008 Aug 1. 72(2):273-7. [Medline].
Sohrabi B, Jamshidi P, Yaghoubi A, et al. Comparison between covered and bare Cheatham-Platinum stents for endovascular treatment of patients with native post-ductal aortic coarctation: immediate and intermediate-term results. JACC Cardiovasc Interv. 2014 Apr. 7(4):416-23. [Medline].
Hayes N, Podnar T, Qureshi S. Collapse of the Advanta V12 Large Diameter covered stent following implantation for aortic coarctation. Catheter Cardiovasc Interv. 2014 Jan 1. 83(1):109-14. [Medline].
Forbes TJ, Kim DW, Du W, et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: an observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol. 2011 Dec 13. 58(25):2664-74. [Medline].
Rao PS, Koscik R. Validation of risk factors in predicting recoarctation following initially successful balloon angioplasty of native aortic coarctations. Am Heart J. 1995. 130:116-21.
Kaine SF, Smith EO, Mott AR, Mullins CE, Geva T. Quantitative echocardiographic analysis of the aortic arch predicts outcome of balloon angioplasty of native coarctation of the aorta. Circulation. 1996 Sep 1. 94(5):1056-62. [Medline].
Rao PS, Waterman B. Relation of biophysical response of coarcted aortic segment to balloon dilatation with development of recoarctation following balloon angioplasty of native coarctation. Heart. 1998 Apr. 79(4):407-11. [Medline].
Isner JM, Donaldson RF, Fulton D, Bhan I, Payne DD, Cleveland RJ. Cystic medial necrosis in coarctation of the aorta: a potential factor contributing to adverse consequences observed after percutaneous balloon angioplasty of coarctation sites. Circulation. 1987 Apr. 75(4):689-95. [Medline].
Ho SY, Somerville J, Yip WC, Anderson RH. Transluminal balloon dilation of resected coarcted segments of thoracic aorta: histological study and clinical implications. Int J Cardiol. 1988 Apr. 19(1):99-105. [Medline].
Elzenga NH, Gittenberger-de Groot AC, Oppenhein-Dekker A. Coarctation and obstructive aortic arch anomalies; their relationship to the ductus arteriosus. Int J Cardiol. 1986. 13:289-308.
Russell GA, Berry PJ, Watterson K, Dhasmana JP, Wisheart JD. Patterns of ductal tissue in coarctation of the aorta in the first three months of life. J Thorac Cardiovasc Surg. 1991 Oct. 102(4):596-601. [Medline].
Tamai H, Igaki K, Kyo E, et al. Initial and 6-month results of biodegradable poly-l-lactic acid coronary stents in humans. Circulation. 2000 Jul 25. 102(4):399-404. [Medline].
Schranz D, Zartner P, Michel-Behnke I, Akinturk H. Bioabsorbable metal stents for percutaneous treatment of critical recoarctation of the aorta in a newborn. Catheter Cardiovasc Interv. 2006 May. 67(5):671-3. [Medline].
Ewert P, Abdul-Khaliq H, Peters B, Nagdyman N, Schubert S, Lange PE. Transcatheter therapy of long extreme subatretic aortic coarctations with covered stents. Catheter Cardiovasc Interv. 2004 Oct. 63(2):236-9. [Medline].
Morris CD, Reller MD, Menashe VD. Thirty-year incidence of infective endocarditis after surgery for congenital heart defect. JAMA. 1998 Feb 25. 279(8):599-603. [Medline].
Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg. 1945 Oct. 14:347-61.
Dotter CT. Transluminally-placed coilspring endarterial tube grafts. Long-term patency in canine popliteal artery. Invest Radiol. 1969 Sep-Oct. 4(5):329-32. [Medline].
Gross RE, Hufnagel CA. Coarctation of the aorta: experimental studies regarding its surgical correction. N Engl J Med. 1945 Sept 6. 233(10):287-93.
Haji-Zeinali AM, Ghasemi M. Coarctoplasty with self-expandable stent implantation for treatment of coarctation of aorta in adults. Arch Iran Med. 2006 Oct. 9(4):348-53. [Medline].
Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosus. Histological study of 35 specimens. Br Heart J. 1979 Mar. 41(3):268-74. [Medline].
Lababidi Z, Madigan N, Wu JR, Murphy TJ. Balloon coarctation angioplasty in an adult. Am J Cardiol. 1984 Jan 15. 53(2):350-1. [Medline].
McCrindle BW, Jones TK, Morrow WR, et al. Acute results of balloon angioplasty of native coarctation versus recurrent aortic obstruction are equivalent. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators. J Am Coll Cardiol. 1996 Dec. 28(7):1810-7. [Medline].
Qureshi SA, Zubrzycka M, Brzezinska-Rajszys G, Kosciesza A, Ksiazyk J. Use of covered Cheatham-Platinum stents in aortic coarctation and recoarctation. Cardiol Young. 2004 Feb. 14(1):50-4. [Medline].
Rao PS. Faculty of 1000 Medicine: Evaluation of Cowley CG et al. Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood. Circulation. 2005; Jun 28. 111 (25):3453-6. [Full Text].
Rao PS. Fatal aortic rupture following balloon angioplasty of aortic recoarctation. Br Heart J. 1991. 66:406-7.
Rao PS. Pseudoaneurysm following balloon angioplasty of aortic coarctation (Editorial). Am Heart J. 1993. 125:1205-6.
Rao PS. Balloon angioplasty of native aortic coarctation. Rao PS, ed. Transcatheter Therapy in Pediatric Cardiology. New York, NY: Wiley-Liss; 1993. 153-196.
Rao PS. Transcatheter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation. Br Heart J. 1986 Sep. 56(3):250-8. [Medline].
Rao PS, Balfour IC, Singh GK, Jureidini SB, Chen S. Bridge stents in the management of obstructive vascular lesions in children. Am J Cardiol. 2001 Sep 15. 88(6):699-702. [Medline].
Rao PS, Thapar MK, Kutayli F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Coll Cardiol. 1989 Jan. 13(1):109-15. [Medline].
Rao PS, Wilson AD, Brazy J. Transumbilical balloon coarctation angioplasty in neonates with critical aortic coarctation. Am Heart J. 1992 Dec. 124(6):1622-4. [Medline].
Rao PS. Balloon angioplasty for aortic recoarctation following previous surgery. Rao PS, ed. Transcatheter Therapy in Pediatric Cardiology. New York, NY: Wiley-Liss; 1993. 197-212.
Rao PS. Technique of balloon valvuloplasty. Rao PS, ed. Transcatheter Therapy in Pediatric Cardiology. New York, NY: Wiley-Liss; 1993. 29-44.
Siblini G, Rao PS, Nouri S, Ferdman B, Jureidini SB, Wilson AD. Long-term follow-up results of balloon angioplasty of postoperative aortic recoarctation. Am J Cardiol. 1998 Jan 1. 81(1):61-7. [Medline].
Sos T, Sniderman KW, Rettek-Sos B, Strupp A, Alonso DR. Percutaneous transluminal dilatation of coarctation of thoracic aorta post mortem. Lancet. 1979 Nov 3. 2(8149):970-1. [Medline].
Sperling DR, Dorsey TJ, Rowen M, Gazzaniga AB. Percutaneous transluminal angioplasty of congenital coarctation of the aorta. Am J Cardiol. 1983 Feb. 51(3):562-4. [Medline].
Wan AW, Lee KJ, Benson LN. Infolding of covered stents used for aortic coarctation: report of two cases. Catheter Cardiovasc Interv. 2014 Jan 1. 83(1):104-8. [Medline].
Wong D, Benson LN, Van Arsdell GS, Karamlou T, McCrindle BW. Balloon angioplasty is preferred to surgery for aortic coarctation. Cardiol Young. 2008 Feb. 18(1):79-88. [Medline].
Zellers TM. Balloon angioplasty for recurrent coarctation of the aorta in patients following staged palliation for hypoplastic left heart syndrome. Am J Cardiol. 1999 Jul 15. 84(2):231-3, A9. [Medline].