CCI: Bailout stenting feasible option for neonates with severe coarctation

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Researchers have found that bailout stenting with a follow-up coarctectomy proved successful in premature infants who suffer from aortic coarctation, and can be performed with low rates of morbidity and complication, according to a study published in the March issue of Catheterization and Cardiovascular Interventions.

"Aortic coarctation is a common congenital condition characterized by a narrowing of the aorta. The narrowed aorta reduces blood flow to the lower extremities and causes heart failure in infants," the authors wrote.

According to the researchers, prostaglandin E1 infusion is the common treatment to restore systemic flow in in this patient population; however, this often yields varying and unsatisfactory results.

Matthias Gorenflo, MD, PhD, and colleagues from the University Clinic in Leuven, Belgium, evaluated data of stent implantation in the aorta in neonates between Jan. 1, 1998 and March 30, 2009. The researchers identified two groups: patients with a native coarctation where surgery was not the best option, and patients with “significant early restenosis after primary surgical coarctectomy or arch repair.”

Surgical repair of critical coarctation can be problematic in premature, critical, complex, or early postoperative neonates.

The researchers performed stent implantation in 15 neonates with severe aortic coarctation: five premature-hypotrophic, six critical and complex cardiac malformations and four early. Eight of 15 infants were premature, while the rest were of 37-41 weeks gestation. During cardiac cath the patients weighed 2.5 kg and were 12 days old. While patients within the first group were more premature, the second group contained infants who had poor hemodynamics.

During the study researchers performed stent removal and arch reconstruction on 12 of 15 patients. After stent removal, patients were observed regularly for nine months post-procedure. In addition, researchers probed the retrograde arch in 14 patients and anterograde catheterization was required in one patient with critical coarctation.

During stent implantation, bare coronary stents with a 4 mm diameter and 10 mm  length were utilized and aortic flow was obtained in 14 patients.

Stents were removed in patients who underwent simple stented coarctation after 2.8 months, while in complex cardiac malformation cases the stents were removed after three months.

The decision to remove the stent was individually considered for each patient and the criteria included hemodynamic stability after cardiogenic shock, adequate body weight or when additional surgery was planned.

According to the researchers, no major complications occurred after PCI except that thrombosis of the femoral artery occurred in two of the 15 patients. In addition, femoral artery patency was preserved in 13 patients and two deaths occurred during follow-up, one from sequelae of perinatal asphyxia and the other from non-procedural-related problems.

While the authors noted that critical neonates do require a surgical intervention, they said that “any therapeutic strategy in such patients must be judged by efficacy, time to establish adequate perfusion, complications early and late, number of procedures, hospitalization times, and, last but not least, final outcome of the arch and the patient.”

“Stenting a coarcted arch can be performed on short notice and acutely improve the patient, and defer surgery to a safer period with adequate weight or stabilized hemodynamics,” the authors wrote.

The authors concluded: “The study shows that in critically ill neonates early stenting (of both native coarctation and early recoarctation post-surgical coarctectomy) followed by later coarctectomy can be performed safely and with good results."