Embed Size (px)
DESCRIPTION
Prevalence Western: 7-14% in CHD Chinese: 0.6-1.6% in CHD Gender: male: female2.1：1(Chinese)
Citation preview
Intervention of Aortic Coarctation:
from Angioplasty to StentGejun Zhang, Zhongying Xu, Shiliang JiangCardiovascular Institute & Fuwai Hospital
CAMS &PUMC, Beijing
Prevalence
• Western: 7-14% in CHD• Chinese: 0.6-1.6% in CHD• Gender: male: female2.1 ： 1(Chinese)
Pathology
• Location: most in aortic isthmus• 2 ~ 5mm （ 75 ％）• Discrete, tubular or long• Concentric or eccentric • Degeneration, or necrosis in aortic wall
Pathology
From Y. Ho
Pathology
Pathophysiology
• Vessel diameter decrease>50%peak systolic gradient >20 mmHg
• Secondary hypertension• Collaterals• Aneurysm formation ： 10 ％ before 20
yrs ； 20 ％ before 30 yrs, ……• Complex CoA
Diagnostic Imaging
• X-ray plain film• Echocardiography• CT• MRI• Angiography
X-ray Plain Film
Echocardiography
MDCT
3D Reconstruction of MDCT
MRA
Balloon Angioplasty• 1979, Sos et al ； 1982, Lock et al• Indication ： native CoA/ recurrent CoA,
SPG>20mmHg ， discrete• Machanism ： tear and stretch of aortic wall• Balloon catheter ： low profile• Advantage: suitable for all patients of any
age• Disadvantage: uncontrolled tear and stretch
of vessel wall
Balloon Angioplasty
Approach ：– Angiography and catheterization– Measurement– Diameter of Balloon ： 2 － 4 times of
diameter of CoA/diameter of normal aortic isthmus ； not above the diameter of descending aorta (diaphragm level)
– 3 － 8 atm ， 5 － 15s ， could repeat for 2－ 4 times ， interval 5 min
– Heperinized; aspirin for 3-6 months
Balloon Angioplasty
• Effective and safe (immediate result)• Complications
– restenosis(5-15%)– aneurysm: (5-40%)– dissection: (1-3%)– femoral artery injury and thrombosis– death ： 0.7 ％
Balloon Angioplasty
• neonates and infants with native CoA – primary surgery– angioplasty only for palliation
• children with native CoA < 30kg– primary surgery in children with complex aortic
arch anomaly– primary angioplasty in children with discrete CoA
• recurrent CoA– Angioplasty or stent
Balloon Angioplasty
Children, male, 4yr and 6month, PG ＝ 70mmHg
Balloon Angioplasty
扩张后 PG ＝ 28mmHg
Balloon Angioplasty
SV, hybrid therapy, Glenn shunt+CoA balloon angioplastySPG: 45mmHg15mmHg
Implantation of Stent• 1991 O’Laughlin, Lock etal• Targets ：
– Getting more diameter– Less vessel wall injury ， less complication– Preventing recoil/ restenosis
• Indication ：– native CoA or recurrent CoA, PSG>20mmHg– children >30 kg, adolescent and adult
• Disadvantage:– Large sheath– Expensive
Implantation of Stent
• Stent:– Bare stent: CP stent; Palmaz stent(8 － 10
series); Genesis XD stent ； eV3 LD stent– Covered stent: covered CP stent
• Balloon– BIB catheter; Z-Med balloon
• Guide wire ： supper stiff (260cm)• Sheath ： Mullins sheath or …
Bare Stent for CoA
Covered CP Stent and BIB Catheter
Implantation of StentApproach• Locating stiff guide wire in ascending aorta• Push sheath across the guide wire• Balloon: length≥stent length; diameter=diameter of
aorta proximal to CoA segment or +1-2mm• Mount stent to balloon• Draw sheath back and leave stent• confirm• Inflation of balloon to expand stent• Deflation of balloon and draw back into sheath• Angiography and catheterization
Implantation of Stent
male ， 19yrs ，PG ＝ 80mmHg
Implantation of Stent
Implantation of Stent
Implantation of Stent
PG=13mmHg
Implantation of StentCoA +PDA （ female ， 45 yrs ）， PG ＝ 60mmHg ， mPAP ＝ 52mmHg
Implantation of Stent
Implantation of Stent
PG ＝ 5mmHg, mPAP=23mmHg
Implantation of StentExperience of Fuwai Hospital ：• 1997-2010, 29 cases ， male
23 ， female 6• 5 cases combined with VSD, 4 cases
with PDA, 1 case with SV ， 3 cases with mild aortic arch hypoplastic, 2 cases with mild AI and MI ， 2 cases after VSD repair
Implantation of Stent
• 10 cases treated by PTA with single or double balloon ， 3 cases treated by PTA and bare stent implantation ， 16 cases treat by covered CP stent implantation
• Technique successful rate: 100 ％• No major complications; no death• Results ： PG<20mmHg in 24, 20-30mmHg in 4,
>30mmHg in 1• Follow-up ： 1 case with aortic arch hypoplastic
after PTA 3 year, then implanted with stent and treated by surgery because of hypertension
Implantation of Stent
Summary• In adult-sized adolescents and adult
patients, stent placement is the treatment of choice for native and recurrent CoA
• In children ≥ 35 kg, stent placement is likely the treatment of choice for native and recurrent CoA
Thanks!
