1. Evolving treatment strategies for aortic coarctation and late complications in teens and adults Eric E. Roselli, MD, Akshat C. Pujara, BA, Lars G. Svensson, MD,PhD, Roy K. Greenberg, MD, Larry Latson, MD

2. Late Coarctation Growing population More survivors of early repair Improved imaging and awareness New treatment modalities Endovascular, hybrid options Patient specific approach Anatomic variations and concomitant disease Bryant et al, J Card Surg, 2008; Kutty et al, Ann Thorac Surg, 2008

3. Objective Review open, hybrid, and endovascular treatment strategies and their indications for patients with late aortic coarctation or post-coarctation repair complications

4. Patients January 2000 to April 2009 n = 95 Aortic Coarctation Post-Repair Complications Mean Age 44 years (range 13 – 71)

5. Inter-positionGraft n Repair Strategies ClamshellRepair Extra- Anatomic Bypass ET with EndoCompletionFrozenETStent-Grafts 12 3 9 5 4 50 Stents Zero Mortality

6. Varied Indications, Multiple Approaches Newly Diagnosed Coarctation Long Segment Coarctation Post-RepairAneurysm RecurrentCoarctation n = 35 5 approaches n = 18 5 approaches n = 40 4 approaches n = 2

7. Conventional Open Repair Interposition Graft Clamshell Approach Normal Arch New Dg Healthy Pt PoorCompliance Abnormal Arch ReoperationConcomitant AVR AVR Ascending Ascending Other Other Durable, Proven

8. Extra-Anatomic Bypass Concomitant valve repair Severe COPD Long segment dz Failed Stenting

9. ET with Endovascular Completion Post-coarct Aneurysm Concomitant valve And Hypo-arch Multiple Reoperation Post-coarct Aneurysm Concomitant valve And Hypo-arch Multiple Reoperation

10. Frozen Elephant Trunk Post-coarctAneurysmHypo-arch

11. Endovascular Bare Stent Stentgraft Branched Recurrent coarct New Dg Post-coarct Aneurysm Normal Arch

12. Late Coarctation and Post-repair Complications Indications and presentation are diverse Approach to repair is patient specific Anatomy Comorbidity Tailored approach to repair is safe