17 year-old male who underwent repair of coarctation of the aorta with subclavian flap in infancy. Recently found to have some degree of re-coarctation, mild hypertension and by MRI was seen to have an aneurysmal dilation. Was referred for evaluation and cath and possible stent implantation. Echocardiography: Mild coarctation with a damped tracing in the abdominal aorta. Bicuspid aortic valve no AS and mild AI wth good ventricular function.
Procedure: Under general anesthesia the patient was draped in the usual sterile fashion and a 5Fr sheath was inserted percutaneously to the RFA. Heparin was administered to keep ACT above 200 during procedure. Intravenous antibiotics were administered. A haemodynamic and angiographic evaluation were performed and demonstrated a peak pressure gradient of 10mmHg across the coarctation. The coarctation was complex with an aneurysm at the site of repair, no LSCA and a narrow section after that area. The flow in that area was abnormal due to the aneurysm causing damped flow and so it was decided to proceed and insert covered stents to improve flow, cover the aneurysm and relieve the stenosis. The transverse measured 15.5mm and the distal coarctation had a diameter of 13mm. An 11Fr long sheath was advanced beyond the coarctation and a 16*48 Bentley BeGraft stent was placed in the distal coarctation and dilated. An additional stent 1648 was telescoped inside reaching up to the transverse arch with a good overlap inside the previously implanted stent and then a final 16*38 stent was implanted reaching up to the left carotid with a good overlap. In this was we achieved good sealing distally and proximally with internal overlap of the stents. Then all 3 stents were post dilated up to 18mm. The balloon was withdrawn and angiography demonstrated the stents to be in very good position with no leak to the aneurysm and no coarctation. There was now a ~8mmHg peak gradient across the arch with the tracing demonstrating a normal (very improved) upstroke in the descending aorta. The sheath was removed and bleeding stopped with an Angioseal VIP 8Fr device and appropriate pressure applied to the groin. No complications.
Things to consider:
- The placement of a 16mm covered stent in a 13mm narrowing knowing that this area would be traversed with balloons and a sheath and other stents. In this situation dislodgement is a possibility. However, since the BeGraft has minimal recoil it was very stable even though it was placed in a mild narrowing with an oversize of just 3mm.
- The overlapping of the stents had to be performed from distal to proximal so that the overlap is telescoped inside vis-à-vis the aortic flow – so as to prevent leaks.
- The stents, since they are open cell, perform a nice anatomical curve as opposed to a sharp angle or rigid tube, while maintaining their diameter due to good radial force.
- The covering has to be 100% so that there is no leak through the ePTFE, at the telescoped overlaps and at the proximal and distal sealing points in the transverse arch and the coarctation.
