Stenting, Surgery Achieve Good Hemodynamic Outcomes in Native Aortic Coarctation

In treatment of native coarctation of the aorta, stenting lowers acute complications compared with surgery or balloon angioplasty alone, while both stenting and surgery achieve good mid-term hemodynamic outcomes, according to the results of an observational study appearing in the December 13, 2011, issue of the Journal of the American College of Cardiology.

According to Thomas J. Forbes, MD, of the Children’s Hospital of Michigan (Detroit, MI), and colleagues, controversy exists as to the optimal treatment for this condition, which accounts for 4% to 5% of all congenital heart defects. To address this issue, Dr. Forbes and researchers from the Congenital Cardiovascular Interventional Study Consortium looked at 350 patients from 36 US institutions who underwent stenting (n = 217), balloon angioplasty (n = 61), or surgery (n = 72) for native coarctation of the aorta between June 2002 and July 2009. Choice of therapy was based on institutional/interventional preference.

Patients receiving stenting were older compared with those receiving surgery or angioplasty (mean age of 17 years vs. 10.0 and 9.0, respectively; P < 0.001 for both comparisons) and weighed more (55 kg vs. 35 and 30, respectively; P < 0.001 for both comparisons).

Early Complications Favor Stenting

For the primary endpoint of upper to lower extremity systolic blood pressure gradient, stenting showed the biggest reduction while also lowering overall complications and aortic wall injuries and achieving the shortest length of stay (table 1).

Table 1. Acute Outcomes

 

^a Not routinely evaluated for surgical patients.

On multivariable analysis controlling for age and weight, the stent group remained superior to balloon angioplasty in terms of upper to lower extremity systolic BP gradient (P = 0.008), while remaining equivalent to surgery.

Importantly, there were no deaths in any group. After adjusting for confounders, stenting was associated with fewer complications than both balloon angioplasty (OR 5.72; 95% CI 1.59-20.52; P = 0.008) and surgery (OR 11.23; 95% CI 3.66-34.51; P < 0.001).

At intermediate-term follow-up beyond 18 months, systolic BP gradient was equivalent among patients receiving stenting (1.9 ± 13.7), angioplasty (5.5 ± 14.3), and surgery (-1.4 ± 13.9; P = 0.118), although surgery showed an advantage in the proportion of patients below a gradient cutoff of 10 mm Hg (75%, 55%, and 90%, respectively, P = 0.032).

There were no differences in resting hypertension among the 3 groups, with complications again lower with stenting, especially compared with balloon angioplasty (table 2).

Table 2. Intermediate-term Complications

 

There were a total of 54 reinterventions at a mean of 1.7-year follow-up, with more than half (n = 35) of these occurring as planned procedures in stent patients at a rate of 16.1%. Unplanned reinterventions were low and similar among the 3 groups.

“Stent patients had significantly lower acute complications compared to surgery patients and [balloon angioplasty] patients,” the researchers conclude. “At short-term and intermediate follow-up, stent and surgical patients achieved superior hemodynamic and integrated aortic arch imaging outcomes compared to [balloon angioplasty].”

A Clear Loser

In a telephone interview with TCTMD, Dr. Forbes commented that of the 3 treatment modalities in the study, “Angioplasty was the one that was the clear loser,” primarily because that group “appeared to have the most likely scenario of complications related to aortic wall issues.”

He explained that in neonates with native coarctation of the aorta, there is no controversy. “Everybody pretty much agrees that surgery should be the treatment of choice,” especially if the classic end-to-end anastomosis repair is possible. “The issue with surgery,” Dr. Forbes added, “is that to get that type of repair as you get older is less likely.”

In the study, 42% of those over age 8 had an end-to-end anastomosis, 25% over age 12, and none over age 16. As they become older, patients with the condition are more likely “to have some other suboptimal [surgical] repair and we know those other types of repairs have an associated aneurysm rate,” Dr. Forbes said.

As a result, he noted, transcatheter therapy has become popular, but there is a trade-off here as well. “If you put a stent in a 4-year-old, they’re going to have to come back at a later age as they grow to dilate the stent further,” Dr. Forbes said. “Anticipated reinterventions are a lot higher with stenting.”

Choice Between Stenting and Surgery Still Unsettled

In terms of clinical guidance from the study, “balloon angioplasty should probably not be the treatment of choice,” Dr. Forbes observed. “But whether or not this will shift things away from balloon angioplasty toward surgery vs. stenting, I don’t know. My gut feeling is if they’re performing balloon angioplasty in these kids, they’ll probably end up moving toward stents.”

But surgery should still play a role, Dr. Forbes stressed. “I would argue that doing a beautiful end-to-end would probably be the best treatment for a child with a pristine, discreet, short-segment coarctation,” he said.

Nevertheless, “one could argue that depending on the anatomy of the coarctation, stent therapy becomes favored over the age of 8 because in this group, the classic end-to-end anastomosis is not possible in the majority of patients,” he said. “The big controversy after this paper is what do you do for the 4- to 8-year-old kid? What happens to them with regard to outcomes?”

 

 

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Source: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;58:2664-2674.

 

 

 

 

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