Balloon coarctation angioplasty in adolescents and adults: Early and intermediate results Twenty-three adolescent and adult patients with native coarctation of the aorta underwent balloon dilatation. Dissection of the aorta developed in one patient. Data were collected on the remaining 22 patients. They ranged in age from 15 to 55 years (mean 23 f 9.2 years). Invasive measurement of the peak systolic gradient (PSG) and biplane angiography were performed before and immediately after angioplasty and at follow-up 4 to 48 months (mean 15 months) later. PSG before dilatation was 37 to 100 mm Hg (mean 66.9 f. 19.9 mm Hg) and decreased to 0 to 30 mm Hg (mean 9.1 i 11 mm Hg) immediately after dilatation (p < 0.001). Restenosis occurred in two patients 6 months after dilatation, and one patient had an incomplete dilatation. These three patients underwent successful redilatation and remained improved 12 to 19 months later. There was no significant change in gradient at repeat catheterization in the remaining 20 patients. PSG was 0 to 20 mm Hg (mean 5.8 + 7.2 mm Hg). Angiography showed that a small aneurysm developed in one patient immediately after dilatation and in another 6 months later. Eleven patients were restudied more than once, and no change in gradient or size of the aneurysm was noted at mean follow-up 25 months after dilatation. This study demonstrated that balloon angioplasty is an effective method of treating adolescent and adult patient with native coarctation of the aorta. However, because of the uncertain natural history of aneurysm after dilatation, this procedure should be considered investigational until much longer follow-up times are available. (AM HEART J 1992;124:167.)
M. E. Fawzy, FRCP, B. Dunn, MD, 0. Galal, MD, PhD, N. Wilson, MRCP, A. Shaikh, MD, R. Sriram, MD, and C. M. G. Duran, MD, PhD. Ki.yadh, Saudi Arabia
In 1979 SOSet al.’ reported the feasibility of balloon dilatation of coarctation of the aorta in postmortem specimens. Singer et al.Z first reported successful balloon dilatation of coarctation in a 7-week-old infant who had restenosis after surgical repair. Subsequently, angioplasty has been found to acutely reduce the gradient of native coarctation,“-I9 but results in small series have suggested a high incidence of restenosis.4-g,l4 Late aneurysm formation may also occur.‘5-10Initial reports were mainly on neonates and children. Few cases of coarctation angioplasty in adult,s have been reported. lo, 18,lg In this report we describe our experience in 23 adolescent and adult patients with native coarctation. Early and intermediate results will be compared and complications will be reviewed.
Front
King
Rerewed
Faisal
Reprint requests: eases. King Faisal Arabia. 411’37351
Specialist
for publication
Hospital Jan.
18, 1991:
M. E. Fawzy. MD, Specialist Hospital.
and
Research
accepted
Centre. Dec.
2, 1991.
Department of Cardiovascular P.O. Box 3354, Riyadh 11211,
DisSaudi
METHODS
Twenty-three adolescentand adult patients with native aortic coarctation underwent balloon angioplasty between July 1986 and May 1990.Their agesranged from 15 to 55 years (mean 23 + 9.2 years). Chest radiography, electrocardiography, and two-dimensional and continuous-wave echocardiography were done in each patient. Procedure. All patients underwent diagnostic catheterization with the useof a percutaneousretrograde catheterization technique and systemic,intravenous heparinization (2000units). An end-hole catheter wasadvanced past the site of coarctation to the ascendingaort.a,and a pull-back pressuregradient acrossthe coarctation and down the descendingaorta was recorded. Biplane aortography in the posterior, anterior, and left lateral projections was performed. The diameter of the descendingthoracic aorta just above the diaphragm was measured and corrected for magnification with the catheter diameter asthe reference. The balloon catheters that were selected had an inflated diameter that was 1 to 2 mm lessthan or equal to the diameter of the descending thoracic aorta near the diaphragm. The balloon catheter wasemptied of air and advanced over a 0.03%inch J guidewire that had been positioned acrossthe site of the coarctation. Balloon inflation with dilute contrast medium was performed by hand until the indentation produced by the co167
Fawz?; et al.
4mencan
T Fig. 1. Peak systolic gradient across coarctation before and immediately after dilatation and at follow-up of 4 to 42 months (mean 15 months). Two patients who experienced restenosis underwent successful redilatation.
arctation disappeared, which was usually between 3 to 5 atm pressure. Inflation was maintained for approximately 10 seconds and was repeated once or twice. The balloon catheter was then exchanged over the guidewire for an angiographic pigtail catheter. Pressure measurements and angiography were repeated. Dilatation was considered successful when the area of coarctation was widely patent on repeat angiography and when the residual pressure gradient was equal to or below 20 mm Hg. Follow-up. Follow-up clinical data, with qualitative assessment of pulses in the upper and lower limbs and measurement of upper-limb blood pressure, were obtained in all patients. Repeat cardiac catheterization with pressure measurement and biplane cineangiography was carried out in all patients 4 to 48 months (mean 15 months) after angioplasty. Eleven patients were restudied more than once by catheterization at a mean follow-up of 25 months. Statistical analysis. Data were expressed as mean ? standard deviation. Student’s t test was used for comparison of data. A probability value of 0.05 or less was considered statistically significant. RESULTS Immediate results. The peak-to-peak systolic pressure gradients (PSG) before and immediately after angioplasty and at follow-up catheterization are summarized in Table I and illustrated in Fig. 1. The PSG was 37 to 100 mm Hg (mean 66.9 i 19.9 mm Hg) before dilatation and decreased t,o 0 to 30 mm Hg
(mean 9.1 i- 11 mm Hg) immediately after dilatation. This change was statistically significant (p < 0.001). Reduction in gradient 520 mm Hg was
Heart
July 1992 Journsl
achieved in 19 of the 22 patients. Three paCents had an unsatisfactory initial reduction in gradient (30 t I t 35 mm Hg) immediately after balloon dilatation (patients 7, 9, and 18; Table I). An undersized balloon catheter was used in these three patients. Neither paradoxic hypertension nor postcoarctectomy syndrome was observed after dilatation of the coarctrttion. Early complications. There were no deaths associ-at,ed with balloon angioplasty. A small aortic dissec tion localized to the coarctation site developed in one patient. This patient had three inflations with a balloon 15 mm in diameter, which resulted in inadequate angiographic improvement. On two occasions the 15 mm balloon burst during inflat.ion, and in ret. respect the rupture may have accounted for the incomplete angiographic result. An 18 mm balloon wa> then used, and although the coarctation was clear!? adequately relieved, the patient experienced immediate and progressive back and chest. pain. Localized dissection was evident on the angiogram Because of persisting back pain surgical repair was performed 4 hours after dilatation. At surgery there was a 3 to 4 cm hematoma constrained only by the aort,ic adventitia. Surgery was uneventful and the patient made a full recovery. Another predisposing factor may have been measurement error in calculat ing the diameter of t.he descending aorta. although an error of 2 mm would seem unlikely to he totally responsible for dissection in an adult patient weighing 60 kg.
One patient developed a small fusiform aneurysm at the site of the dilatation as demonst,rated by angiography immediat,ely after dilatation. An oversized balloon catheter 3 mm larger than the diameter of the descending thoracic aorta at the diaphragm level was used (patient 14: Table I), most likely because of an error in calculating the magnification factor. This was the first patient in the study. Thrombosis of the right femoral artery developed in one patient (patient 15) and required surgical thrombect,oml-. Follow-up. Clinical follow-up showed the blood pressure to be normal in seven patients (Table I). and in another 10 patients hypertension was well controlled with a small dose of atenolol(50 mg/day). Two pat,ients who experienced restenosis had a residual gradient immediately after dilatation (patients 7 and 1X; Table I). In the remaining 20 pat,ients t.he PSG did not change significantly at repeat catheterization 4 t (1 48 months (mean 15 months) later, with gradients of’ 0 to 20 mm Hg (mean 5.X ~_t7.1 mm Hg). The two patients who experienced restenosis and the one who had an incomp1et.e dilatation underwent. successful redilation with the appropriate size balloc)n catheter and remained improved 12 to 19 months later. ElevtJtI
Volume Number
Table
-_
124 1
Balloon
angioplasty
in adults
169
1. Hemodynamic data in 22 patients undergoing coarctation balloon angioplasty Coarctation
Pa:ient
coarctation
gradient
Ace (yrl
A
B
c
19 23 16 15 21 20 24
60 55 60 55 100 52 94
10 9 15 4 0 20 35
13 9 10 5 0 20 70
14 3 f,
60 90
5 30
:; 3!!
19 311 16 40
64 7x 6U 40
:3 0 10 10
:31
0
0
74
3
0
88
19
16 16 “3
70 60 60
12 30 16
11 .j .j 0
19 ‘9
73 61
0 3
0 16
40
100
0
0
(mm
n
Size
Hg)
E
-
15
0 -
15
-
-
-
(mm)
Blood
pressure
(mm
Hg) Drugs lmgldayj
Before
At follouMqJ
Recath. (mo)
15 18 12 13 15 12 19
180/130 155170 160/110 190/120 170/100 160/90 190/70
110/70 130/70 110/70 110/70 1 lOi80 130/70 130/70
24112 7112 48112 4112 30/12 15112 19/12
Atenolol (50) Nil Atenolol(50) Atenolol (50) Nil Nil Atenolol(50) Restenosed Nifedipine
16 18
15 15
150190 170/106
12a/so 110/70
7112 12112
Nil
18.5 18 15 13
19 18 15 12
170/106 190/80 160/80 140/90
110/80 110/70 110/80 105/70
30/12 13/12 18/l” 6112
17
20
200/90
130185
38/12
18
18
150/90
120/70
9112
Nil
18
18
160/100
140/90
4112
Atenolol (100) Nifedipine
11 12 19
10 9 18
150/70 150/90 190/100
1”0/70 1 IO/60 135155
4112 18/l:! 31112
20 15
20 15
170/100 145195
120/60 120/80
4112 18/12
18
18
lSO/lOO
130/80
8112
Aorta
Balloon
17 18 14 13 15 13.5 25
Complication
(40)
Atenolol(50) Incomplete dilatation -Nil Nil Atenolol(50) Captopril Small aneurysm (7.5) Atenolol (100) Small Nifedipine aneurysm (40)
Femoral thrombosis
-
-
-
15
15 -
-
(40)
Atenolol (50) Atenolol (50) Restenosis Atenolol (50) Small aneurysm Atenolol (50) Atenolol (50) Nifedipine (40)
A, Before dilatation; R, immediately tion: Rrcath.. recatheterisation.
after; C.
repeatcatheterization:
II, immediately
patients underwent repeat catheterization more than once at a mean follow-up of 12 to 48 months (mean 25 months) after dilatation, and neither the gradient nor the aneurysm size increased (Table II). In all patients with successful balloon dilatation the area of coarctation was widely patent after dilatation (Fig. 2j. In one patient a small aneurysm at the site of dilatation was observed 6 months later (Fig. 3). DISCUSSION
Several reports suggested good immediate results of’ balloon angioplasty in native coarctation in children. Few casesof coarctation balloon angioplasty in adults have been reported.lO, 18,I9 We report successful immediate results in 18 of 23 patients with native coarctation. Several groups of authors4-g, l4 reported a 10 5 to 43 5’; recoarctation rate at a follow-up 1 to
after second dilatation;
Atenolol (50)
E, repeat catheterization
after second dilata-
31 months after angioplasty in infants and children. We noted recoarctation in two (95 ) patients at follow-up 4 to 48 months (mean 15 months) after angioplasty. These two patients had a residual gradient greater than 20 mm Hg immediately after dilatation. In the remaining 20 patients there was no significant change in gradient at repeat catheterization 4 to 48 months (mean 15 months) after angioplasty. There was also no change in gradient or the size of the aneurysm in the patients restudied more than once at a mean follow-up of 25 months. Rao et a1.17identified risk factors for recoarcation in infants and children. Perhaps the difference in age can explain the low incidence of recoarction in adult patients undergoing angioplasty. Angioplasty in aortic coarctation produces a controlled injury of the intima and part of the media, in-
Fig. 2. A, Aortogram of patient 5 (Table I) before dilatation showsmembranecoarctation !whric, :I, I’I? t ~. B, Immediately after dilatation. C, Thirt,y months later. Coarctation site is widely patent and there j’\ 11,~
aneurysm formation.
II. Coarctation balloon angioplasty: patients restudied more than once
Table
Patient 1 3 5 6 7
10 1"
Gradient before (mm Hg) 60 60 100 80 94
Gradient immediate/\ after (mm Hgi 10 15 0 20 35
Gradient at first restud>, (mm Hgi 1:i 10 0 “0 70
Gradient f&wup frnu) I6 1 .i I) “0 1:;
IO
0
24 48 :30 15 19
64
3
I)
II
10 0
6 0
I(1 i!
10
14
6(J 37
18 :c?i
19
60
16
10
0
0
:-II
creasing the vessel diameter and healing over a period of months by way of a fibrous scar.20% 21However, uncontrolled damage of the aortic wall at the time of dilatation can also occur. Observation of such patients at operation has shown complete rupture of the media, with progression into a saccular aneurysm.” Factors determining such damage are not well known. A 10 % to 55Y incidence of aneurysm formation has been reported in infants and childrenSel’ at follow-up 7 to 24 months after balloon coarctation angioplasty. We performed repeat angiography on all of
:10
nl
No change No change Nt, change NI, change Restenoxis redilated and remained 9, 19 mllnrhs later Incomplete dilatation redilat,etl No change No change *Small aneurysm (did not mcrease In sue) Rwtenosrd redilated (remained dilated one year later) Small aneurysm (did not increase in size)
our patients 4 to 48 months (mean 15 months) after angioplasty and noted an aneurysm in two (9 “c ) of 22 patients. One patient underwent dilatation with an oversized balloon catheter and in the second patient the aneurysm was not related to the balloon diameter. Other investigatorsl”. I” did not observe aneurysms on the angiographic follow-up of dilatation of native coarctation. However, these investigators did not, do follow-up angiography in all of their patients. The aneurysm observed in our patient was small. did not increase in size on repeat angiography more
Volume
124
Number
1
Balloon
coarctation
angioplasty
in adults
171
3. Aortogram of patient 21 (Table I) immediately after dilatation (A) and 6 months later (B); note small saccular aneurysm (white arrow).
Fig.
t.han once, and did not appear to represent an immediate threat to the patient. Surgical repair was not recommended. The natural history of aneurysms t,hat may occur after balloon dilatation of coarctation is unknown. Close follow-up is required for patients with or without an aneurysm. Meticulous care and appropriate choice of balloon size is vital to avoid overdistention of the media of the aortic segments adjacent to the coarctation. The maximum diameter of t.he balloon should be equal to or 1 to 2 mm less t,han the diameter of the descending thoracic aorta at t,he level of the diaphragm as measured on the video monitor after correct,ion of magnification. Tips of the guidewire or catheters should not be manipulated at the site of coarctation dilatation to avoid intimal dissect,ion.
8.
9.
10.
11.
12.
13.
14. REFERENCES
1.
2.
3.
4.
5.
6.
7.
SOS T, SnidermanKW,
Rettek SOS B, Strapp A, Alonso DR. Percutaneous transluminal dilatation of coarctation of the thoracic aorta postmortem. Lancet 1979;2:970-1. Singer MI, Rowen M, Dorsey T.J. Transluminal aortic balloon angioplasty for coarctation of the aorta in the newborn. AM HEART J 198o~103:181-2. Finlev ,JP, B&ilieu RG, Nonton MA, Roy DL. Balloon catheter dilatation of coarctat,ion of the aorta in young infants. Br IHeart J 1983;50:41154. Lock JE. Bass JL. Amolatz K. Fuhrman BP. CastanedaZuniga W. Balloon dilation angioplasty of aortic doarctation in infants and children. Circulation 1983;68:109-16. Marvin WJ, Mahoney LT. Rose EF. Pathologic sequelae of balloon dilation angioplasty for unoperated coarctation of the aorta in children [Abstract]. J Am Co11 Cardiol 1986;7:117A. Cooper RS, Ritter SB, Rothe WB, Chen EK, Griepp R, Golinko RJ. Angioplasty for coarctation of the aorta: long term results. Circulation 1987:75:600-4. Wren c’, Peart I, Barn H. Hunter S. Balloon dilatation of un-
15 16.
17.
18. 19.
20.
21.
operated aortic coarctation: immediate results and one year follow-up. Br Heart J 1987;58:369-73. Beekman RH, Rocchini AP, Dick M II, Snider AR, Crowley D, Serwer GA, Spicer RL, Rosenthal A. Percutaneous angioplasty for native coarctation of the aorta. J Am Co11 Cardiol 1987;10:1078-84. Morrow WR, Vick GW III, Nihill MR, Rokey R, Johnston DL, Hedrick TD, Mullins CE. Balloon dilatation of unoperated coarctation of the aorta: short and intermediate term result. J Am Co11 Cardiol 1988;11:133-8. De Lezo JS, Sancho M, Pan M, Romero M, Olivera C, Lugue M. Angiographic follow-up after balloon angioplasty for coarctation of the aorta. J Am Co11 Cardiol 1989;13:689-95. Sperling DR, Dorsey TJ, Rowen M, Gazzaniga AB. Percutaneous transluminal angioplasty of congenital coarctation of aorta. Am d Cardiol 1983;51:562-4. Lababidi ZA, Daskalopoulos DA, Stoeckle H Jr. Transluminal balloon coarctation angioplasty: experience with 27 patients. Am J Cardiol 1984;54:1288-91. Brodsky SJ. Percutaneous balloon angioplasty: treatment for congenital coarctation of the aorta and congenital valvular pulmonary stenosis. Am J Dis Child 1984;138:851-3. Rao PS. Naiiar HN. Mardini MK. Solvmar L. Thanar MK. Balloon angyoplasty for coarctation of “the aorta: immediate and long-term results. AM HEART J 1988;115:657-64. Rao PS. Balloon angioplasty for coarctation of the aorta in infants. J Pediatr 1987;110:713-8. Allen HD. Marx GR, Ovitt TW, Goldberg SJ. Balloon dilation angioplasty for coarctation of the aorta. Am J Cardiol 1986;57:828-32. Rao PS, Thapar MK, Kutayli F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Co11 Cardiol 1989;13:109-15. Lababidi Z. Madigan N, Wu JR, Murphy TJ. Balloon coarctation angioplasty in an adult. Am J Cardiol 1984;53:350-1. Attia I, Lababidi Z. Early results of balloon angioplasty of native aortic coarctation in young adults. Am .J Cardiol 1988;61:930-1. Lock JE, Niemi T, Burke BA, Einzig S, Castaneda-Zuniga WR. Transcutaneous angioplasty of experimental aortic coarctation. Circulation 1982;66:1280-6. Lock JE. Castaneda-Zuniga WR. Bass JL. Foker JE. Amnlatz K, Anderson RW. Balloon dilatation of excised aortic cbarctations. Radiology 1982;143:689-91.
M. E. Fawzy, FRCP, B. Dunn, MD, 0. Galal, MD, PhD, N. Wilson, MRCP, A. Shaikh, MD, R. Sriram, MD, and C. M. G. Duran, MD, PhD. Ki.yadh, Saudi Arabia
In 1979 SOSet al.’ reported the feasibility of balloon dilatation of coarctation of the aorta in postmortem specimens. Singer et al.Z first reported successful balloon dilatation of coarctation in a 7-week-old infant who had restenosis after surgical repair. Subsequently, angioplasty has been found to acutely reduce the gradient of native coarctation,“-I9 but results in small series have suggested a high incidence of restenosis.4-g,l4 Late aneurysm formation may also occur.‘5-10Initial reports were mainly on neonates and children. Few cases of coarctation angioplasty in adult,s have been reported. lo, 18,lg In this report we describe our experience in 23 adolescent and adult patients with native coarctation. Early and intermediate results will be compared and complications will be reviewed.
Front
King
Rerewed
Faisal
Reprint requests: eases. King Faisal Arabia. 411’37351
Specialist
for publication
Hospital Jan.
18, 1991:
M. E. Fawzy. MD, Specialist Hospital.
and
Research
accepted
Centre. Dec.
2, 1991.
Department of Cardiovascular P.O. Box 3354, Riyadh 11211,
DisSaudi
METHODS
Twenty-three adolescentand adult patients with native aortic coarctation underwent balloon angioplasty between July 1986 and May 1990.Their agesranged from 15 to 55 years (mean 23 + 9.2 years). Chest radiography, electrocardiography, and two-dimensional and continuous-wave echocardiography were done in each patient. Procedure. All patients underwent diagnostic catheterization with the useof a percutaneousretrograde catheterization technique and systemic,intravenous heparinization (2000units). An end-hole catheter wasadvanced past the site of coarctation to the ascendingaort.a,and a pull-back pressuregradient acrossthe coarctation and down the descendingaorta was recorded. Biplane aortography in the posterior, anterior, and left lateral projections was performed. The diameter of the descendingthoracic aorta just above the diaphragm was measured and corrected for magnification with the catheter diameter asthe reference. The balloon catheters that were selected had an inflated diameter that was 1 to 2 mm lessthan or equal to the diameter of the descending thoracic aorta near the diaphragm. The balloon catheter wasemptied of air and advanced over a 0.03%inch J guidewire that had been positioned acrossthe site of the coarctation. Balloon inflation with dilute contrast medium was performed by hand until the indentation produced by the co167
Fawz?; et al.
4mencan
T Fig. 1. Peak systolic gradient across coarctation before and immediately after dilatation and at follow-up of 4 to 42 months (mean 15 months). Two patients who experienced restenosis underwent successful redilatation.
arctation disappeared, which was usually between 3 to 5 atm pressure. Inflation was maintained for approximately 10 seconds and was repeated once or twice. The balloon catheter was then exchanged over the guidewire for an angiographic pigtail catheter. Pressure measurements and angiography were repeated. Dilatation was considered successful when the area of coarctation was widely patent on repeat angiography and when the residual pressure gradient was equal to or below 20 mm Hg. Follow-up. Follow-up clinical data, with qualitative assessment of pulses in the upper and lower limbs and measurement of upper-limb blood pressure, were obtained in all patients. Repeat cardiac catheterization with pressure measurement and biplane cineangiography was carried out in all patients 4 to 48 months (mean 15 months) after angioplasty. Eleven patients were restudied more than once by catheterization at a mean follow-up of 25 months. Statistical analysis. Data were expressed as mean ? standard deviation. Student’s t test was used for comparison of data. A probability value of 0.05 or less was considered statistically significant. RESULTS Immediate results. The peak-to-peak systolic pressure gradients (PSG) before and immediately after angioplasty and at follow-up catheterization are summarized in Table I and illustrated in Fig. 1. The PSG was 37 to 100 mm Hg (mean 66.9 i 19.9 mm Hg) before dilatation and decreased t,o 0 to 30 mm Hg
(mean 9.1 i- 11 mm Hg) immediately after dilatation. This change was statistically significant (p < 0.001). Reduction in gradient 520 mm Hg was
Heart
July 1992 Journsl
achieved in 19 of the 22 patients. Three paCents had an unsatisfactory initial reduction in gradient (30 t I t 35 mm Hg) immediately after balloon dilatation (patients 7, 9, and 18; Table I). An undersized balloon catheter was used in these three patients. Neither paradoxic hypertension nor postcoarctectomy syndrome was observed after dilatation of the coarctrttion. Early complications. There were no deaths associ-at,ed with balloon angioplasty. A small aortic dissec tion localized to the coarctation site developed in one patient. This patient had three inflations with a balloon 15 mm in diameter, which resulted in inadequate angiographic improvement. On two occasions the 15 mm balloon burst during inflat.ion, and in ret. respect the rupture may have accounted for the incomplete angiographic result. An 18 mm balloon wa> then used, and although the coarctation was clear!? adequately relieved, the patient experienced immediate and progressive back and chest. pain. Localized dissection was evident on the angiogram Because of persisting back pain surgical repair was performed 4 hours after dilatation. At surgery there was a 3 to 4 cm hematoma constrained only by the aort,ic adventitia. Surgery was uneventful and the patient made a full recovery. Another predisposing factor may have been measurement error in calculat ing the diameter of t.he descending aorta. although an error of 2 mm would seem unlikely to he totally responsible for dissection in an adult patient weighing 60 kg.
One patient developed a small fusiform aneurysm at the site of the dilatation as demonst,rated by angiography immediat,ely after dilatation. An oversized balloon catheter 3 mm larger than the diameter of the descending thoracic aorta at the diaphragm level was used (patient 14: Table I), most likely because of an error in calculating the magnification factor. This was the first patient in the study. Thrombosis of the right femoral artery developed in one patient (patient 15) and required surgical thrombect,oml-. Follow-up. Clinical follow-up showed the blood pressure to be normal in seven patients (Table I). and in another 10 patients hypertension was well controlled with a small dose of atenolol(50 mg/day). Two pat,ients who experienced restenosis had a residual gradient immediately after dilatation (patients 7 and 1X; Table I). In the remaining 20 pat,ients t.he PSG did not change significantly at repeat catheterization 4 t (1 48 months (mean 15 months) later, with gradients of’ 0 to 20 mm Hg (mean 5.X ~_t7.1 mm Hg). The two patients who experienced restenosis and the one who had an incomp1et.e dilatation underwent. successful redilation with the appropriate size balloc)n catheter and remained improved 12 to 19 months later. ElevtJtI
Volume Number
Table
-_
124 1
Balloon
angioplasty
in adults
169
1. Hemodynamic data in 22 patients undergoing coarctation balloon angioplasty Coarctation
Pa:ient
coarctation
gradient
Ace (yrl
A
B
c
19 23 16 15 21 20 24
60 55 60 55 100 52 94
10 9 15 4 0 20 35
13 9 10 5 0 20 70
14 3 f,
60 90
5 30
:; 3!!
19 311 16 40
64 7x 6U 40
:3 0 10 10
:31
0
0
74
3
0
88
19
16 16 “3
70 60 60
12 30 16
11 .j .j 0
19 ‘9
73 61
0 3
0 16
40
100
0
0
(mm
n
Size
Hg)
E
-
15
0 -
15
-
-
-
(mm)
Blood
pressure
(mm
Hg) Drugs lmgldayj
Before
At follouMqJ
Recath. (mo)
15 18 12 13 15 12 19
180/130 155170 160/110 190/120 170/100 160/90 190/70
110/70 130/70 110/70 110/70 1 lOi80 130/70 130/70
24112 7112 48112 4112 30/12 15112 19/12
Atenolol (50) Nil Atenolol(50) Atenolol (50) Nil Nil Atenolol(50) Restenosed Nifedipine
16 18
15 15
150190 170/106
12a/so 110/70
7112 12112
Nil
18.5 18 15 13
19 18 15 12
170/106 190/80 160/80 140/90
110/80 110/70 110/80 105/70
30/12 13/12 18/l” 6112
17
20
200/90
130185
38/12
18
18
150/90
120/70
9112
Nil
18
18
160/100
140/90
4112
Atenolol (100) Nifedipine
11 12 19
10 9 18
150/70 150/90 190/100
1”0/70 1 IO/60 135155
4112 18/l:! 31112
20 15
20 15
170/100 145195
120/60 120/80
4112 18/12
18
18
lSO/lOO
130/80
8112
Aorta
Balloon
17 18 14 13 15 13.5 25
Complication
(40)
Atenolol(50) Incomplete dilatation -Nil Nil Atenolol(50) Captopril Small aneurysm (7.5) Atenolol (100) Small Nifedipine aneurysm (40)
Femoral thrombosis
-
-
-
15
15 -
-
(40)
Atenolol (50) Atenolol (50) Restenosis Atenolol (50) Small aneurysm Atenolol (50) Atenolol (50) Nifedipine (40)
A, Before dilatation; R, immediately tion: Rrcath.. recatheterisation.
after; C.
repeatcatheterization:
II, immediately
patients underwent repeat catheterization more than once at a mean follow-up of 12 to 48 months (mean 25 months) after dilatation, and neither the gradient nor the aneurysm size increased (Table II). In all patients with successful balloon dilatation the area of coarctation was widely patent after dilatation (Fig. 2j. In one patient a small aneurysm at the site of dilatation was observed 6 months later (Fig. 3). DISCUSSION
Several reports suggested good immediate results of’ balloon angioplasty in native coarctation in children. Few casesof coarctation balloon angioplasty in adults have been reported.lO, 18,I9 We report successful immediate results in 18 of 23 patients with native coarctation. Several groups of authors4-g, l4 reported a 10 5 to 43 5’; recoarctation rate at a follow-up 1 to
after second dilatation;
Atenolol (50)
E, repeat catheterization
after second dilata-
31 months after angioplasty in infants and children. We noted recoarctation in two (95 ) patients at follow-up 4 to 48 months (mean 15 months) after angioplasty. These two patients had a residual gradient greater than 20 mm Hg immediately after dilatation. In the remaining 20 patients there was no significant change in gradient at repeat catheterization 4 to 48 months (mean 15 months) after angioplasty. There was also no change in gradient or the size of the aneurysm in the patients restudied more than once at a mean follow-up of 25 months. Rao et a1.17identified risk factors for recoarcation in infants and children. Perhaps the difference in age can explain the low incidence of recoarction in adult patients undergoing angioplasty. Angioplasty in aortic coarctation produces a controlled injury of the intima and part of the media, in-
Fig. 2. A, Aortogram of patient 5 (Table I) before dilatation showsmembranecoarctation !whric, :I, I’I? t ~. B, Immediately after dilatation. C, Thirt,y months later. Coarctation site is widely patent and there j’\ 11,~
aneurysm formation.
II. Coarctation balloon angioplasty: patients restudied more than once
Table
Patient 1 3 5 6 7
10 1"
Gradient before (mm Hg) 60 60 100 80 94
Gradient immediate/\ after (mm Hgi 10 15 0 20 35
Gradient at first restud>, (mm Hgi 1:i 10 0 “0 70
Gradient f&wup frnu) I6 1 .i I) “0 1:;
IO
0
24 48 :30 15 19
64
3
I)
II
10 0
6 0
I(1 i!
10
14
6(J 37
18 :c?i
19
60
16
10
0
0
:-II
creasing the vessel diameter and healing over a period of months by way of a fibrous scar.20% 21However, uncontrolled damage of the aortic wall at the time of dilatation can also occur. Observation of such patients at operation has shown complete rupture of the media, with progression into a saccular aneurysm.” Factors determining such damage are not well known. A 10 % to 55Y incidence of aneurysm formation has been reported in infants and childrenSel’ at follow-up 7 to 24 months after balloon coarctation angioplasty. We performed repeat angiography on all of
:10
nl
No change No change Nt, change NI, change Restenoxis redilated and remained 9, 19 mllnrhs later Incomplete dilatation redilat,etl No change No change *Small aneurysm (did not mcrease In sue) Rwtenosrd redilated (remained dilated one year later) Small aneurysm (did not increase in size)
our patients 4 to 48 months (mean 15 months) after angioplasty and noted an aneurysm in two (9 “c ) of 22 patients. One patient underwent dilatation with an oversized balloon catheter and in the second patient the aneurysm was not related to the balloon diameter. Other investigatorsl”. I” did not observe aneurysms on the angiographic follow-up of dilatation of native coarctation. However, these investigators did not, do follow-up angiography in all of their patients. The aneurysm observed in our patient was small. did not increase in size on repeat angiography more
Volume
124
Number
1
Balloon
coarctation
angioplasty
in adults
171
3. Aortogram of patient 21 (Table I) immediately after dilatation (A) and 6 months later (B); note small saccular aneurysm (white arrow).
Fig.
t.han once, and did not appear to represent an immediate threat to the patient. Surgical repair was not recommended. The natural history of aneurysms t,hat may occur after balloon dilatation of coarctation is unknown. Close follow-up is required for patients with or without an aneurysm. Meticulous care and appropriate choice of balloon size is vital to avoid overdistention of the media of the aortic segments adjacent to the coarctation. The maximum diameter of t.he balloon should be equal to or 1 to 2 mm less t,han the diameter of the descending thoracic aorta at t,he level of the diaphragm as measured on the video monitor after correct,ion of magnification. Tips of the guidewire or catheters should not be manipulated at the site of coarctation dilatation to avoid intimal dissect,ion.
8.
9.
10.
11.
12.
13.
14. REFERENCES
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6.
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