Intraoperative Hybrid Stenting of Recurrent Coarctation and Arch Hypoplasia with Large Stents in Patients with Univentricular Hearts

Objective: Obstruction of the reconstructed aortic arch, tubular hypoplasia and recurrent coarctation (RC) is an important risk factor after the Norwood procedure or similar surgery. Balloon angioplasty (BA) may be effective but pressure gradient relief is often incomplete, with a high incidence of restenosis usually within the first year. Percutaneous interventions may have an increased risk due to limited vascular access or a very tortuous catheter course. Combining operative and interventional approaches (hybrid procedures) with direct puncture of the heart or the great vessels may facilitate implantation of even large devices. For the past two years we have adopted the concept of intraoperative hybrid stenting of RC and arch hypoplasia with large stents in patients with univentricular hearts as standard care procedure.

Method/Result: Intraoperative stenting of the aortic arch was scheduled in 14 patients; in 12 the procedure was performed during surgery for BCPS and in 2 during Fontan completion. The median age was 5.23 months, the weight 5.45 kg, height 61 cm. All patients had a catheter investigation before, and in eight a balloon dilatation was performed. Five patients presented with tubular hypoplasia, nine with stenosis in the distal arch. The mean diameter of the distal arch at the level of the subclavian artery was 10.5 mm, the diameter at the coarctation was 5.1 mm, and the diameter of the aorta at the level of the diaphragm was 7.8 resulting in a ratio Coa/Diaphragm of 0.64. Intraoperative stenting was performed in 13/14 patients; in one patient the previous balloon dilatation showed excellent result. Intraoperative measurement revealed a coarctation diameter of 5.1 mm (mean, SD 1.6 mm), a diameter of the aorta at the diaphragm of 7.9 mm (mean, SD 1.9 mm) and a ratio Coa/Diaphragm of 0.63. Stents were implanted with a balloon diameter of 9.5 mm (Mean, SD 1.3 mm) resulting in a final diameter of 9.6 mm (mean, SD 2.3 mm) and a ratio Coa/Diaphragm of 1.2. There is no re-coarctation at a mean follow-up of 7.3 months (range: 3–24) and a maximum flow velocity as measured by echo of 2 m/s.

Conclusion: This hybrid approach of hypoplastic and/or stenotic distal arches is an easy and safe concept to address the problem of recurrent arch obstruction and hypoplasia. The use of large stents enables the potential for redilatation to adult size diameters later on.