Stenting for relief of stenosis in narrowed vessels is now common practice both in interventional cardiology and interventional radiology, with many options to choose from as to delivery systems, balloons, and types of stent. When dealing with coarctation of the aorta, these choices are limited due to the special considerations that need to be taken into account, and this chapter provides a practical framework for the interventionalist to approach this straightforward but challenging lesion (Figure 39-1).
(A) Aortogram lateral projection demonstrating a neonatal discrete coarctation with hypoplastic isthmus. (B) Aortogram anteroposterior (AP) projection demonstrating a discrete coarctation in a 14-year-old boy. Note poststenotic dilatation. (C) Aortogram AP projection demonstrating a discrete coarctation in a 32-year-old woman. Note tortuosity, poststenotic dilatation, and enlarged left internal mammary artery.
Coarctation of the aorta occurs in approximately 7% of live births with congenital heart disease, and although there are many variants of the anatomy and associated lesions, the effects of the narrowing of the aortic lumen have the common denominator of increased left ventricular afterload, upper body hypertension, flow disturbance in the thoracic aorta, and decreased perfusion to the lower body.1,2 Presentation is dependent on the balance between the degree of flow disturbance and the compensatory mechanisms available to overcome it, and therefore, if survived in infancy, coarctation is often discovered in adolescence or adulthood when undergoing a workup for hypertension (Figure 39-2).
(A) Aortogram in a 52-year-old woman with a discrete coarctation of the thoracic aorta. There is a tiny jet of contrast adjacent to the catheter, and the descending aorta is not seen. (B) The descending aorta distal to the coarctation is seen clearly as it fills late from collaterals, while the ascending aorta is already clear of contrast.
Untreated coarctation has a poor prognosis, with most patients suffering from significant morbidities associated with hypertension including premature death due to heart failure, cerebovascular accidents, and premature coronary artery disease.3 Surgery, balloon angioplasty, or stent implantation usually provides relief of the obstruction; however, recoarctation from scarring, failure to match somatic growth and tissue ingrowth,4–7 and acute and late aortic wall injury are ongoing issues.
Surgery has been in practice since 19448 and is still the preferred treatment for infants with native coarctation; however, in older patients, surgical complications are more common and occasionally can be severe, particularly when an adequate collateral circulation has not developed, and spinal cord damage can ensue.9...