Technique of interventional repair in adult aortic coarctation

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Presentation transcript:

Technique of interventional repair in adult aortic coarctation Stephan Kische, MD, Henrik Schneider, MD, Ibrahim Akin, MD, Jasmin Ortak, MD, Tim C. Rehders, MD, Tushar Chatterjee, MD, Christoph A. Nienaber, MD, Hüseyin Ince, MD Journal of Vascular Surgery Volume 51, Issue 6, Pages 1550-1559 (June 2010) DOI: 10.1016/j.jvs.2009.12.063 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Noninvasive assessment of aortic pathology in a patient with severe coarctation. A composite of volume-rendered images obtained from a 64-slice multidetector CT angiogram is presented. A, Classic anatomic features including discrete aortic narrowing (arrow) and hypoplastic aortic arch are clearly visualized in lateral projection. B, Note the detailed display of the collateral network and a concomitant ectasia of the ascending aorta (ASC). *Indicates the right internal mammarian artery Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 A selection of endovascular devices are currently available for the transcatheter repair of adult coarctation. A, The CP stents by NuMed are made of platinum wire with rows of zigzags to allow full-size expansion with minimal shortening and good radial strength. B, The ev3 Intrastent Max LD is expandable to full size, is flexible, and does not significantly shorten. C, The “sigma'' hinge in the Genesis stents allows the stents to flex around curves and prevents significant shortening on expansion; however, these stents cannot be expanded beyond 18 mm. D, The NuMED Balloon-in-Balloon catheter allows even expansion of a hand-mounted stent for safer and more reliable stent positioning. Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 Serial aortograms in the left oblique projection depict (A) severe primary coarctation before angioplasty, (B) predilatation angioplasty, (C) implantation of a 28-mm self-expanding nitinol Sinus-XL stent, and (D) postdilatation angioplasty. E, Significant increase in isthmus diameter from 3 to 24 mm is seen in the final aortogram and was reconfirmed (F) by computed tomography angiography 3 months after stent deployment. Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 Schematic representation of the “arterial railway.” An extra-stiff guidewire is advanced from the femoral artery to the right subclavian artery. This wire is snared in the innominate artery, exteriorized through the right brachial sheath, and fixed in place with a hemostat clamp at both ends. The railway provides an extremely stable platform, allowing minimal movement of the balloon/stent assembly during deployment. This strategy may decrease the risk of stent malposition and could be particularly useful in anatomically complex cases. Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 Implantation of a 39-mm covered Cheatham platinum (CP) stent for the treatment of subatretic aortic coarctation. A, Composite of two frames of the same angiogram (early and late phase). The procedure was performed in two steps: (B) first, the stent was implanted with only moderate dilatation of the subatretic area; (C) after 6 months, the stent was definitively dilated to completely relieve the stenosis. Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 6 Delivery of a covered stent inside a previously implanted bare stent is shown. A, A Left anterior oblique angiogram after stent deployment demonstrates occlusion of flow to the left subclavian artery. B, During recannulization of the left subclavian artery, perforation of a covered stent with the stiff end of coronary wire was followed by dilation with a coronary balloon. C, Postprocedural angiogram shows excellent result, with brisk flow to the left subclavian artery. Journal of Vascular Surgery 2010 51, 1550-1559DOI: (10.1016/j.jvs.2009.12.063) Copyright © 2010 Society for Vascular Surgery Terms and Conditions