Catheter Interventions for Highly Complex Recoarctations of the Aorta in Adults with Congenital Heart Disease beyond Standard Procedures Using Innovative Imaging Methods

Objectives: Endovascular stent implantation is well established as a low-risk treatment option for recoarctations of the aorta (Re-CoA), especially in adults with congenital heart disease (ACHD). However, very complex pathologies are often being referred for surgery. The aim of our retrospective study was to analyze within the past 5 years of cases of Re-CoA in ACHD with the highest degree of complexity regarding catheter and imaging strategies, as well as outcome.

Methods: Case 1: a high-resolution computed tomography (HR-CT) scan of a 55-year-old patient confirmed a suspected CoA directly distal to an ectatic left subclavian artery (LSA) with an ectatic aortic arch and descending aorta. Due to the dilatation of the aorta, an intervention with a balloon-expanding stent was not an option. Therefore, it was decided to use a new approach which has not been published before. The CoA was treated with a self-expanding stent graft which was fenestrated in situ with a laser catheter using image fusion from HR-CT data to ensure the perfusion of the LSA. Case 2: a 51-year-old patient showed a Re-CoA with three-dimensional (3D) HR-CT. The patient underwent a two-step operation. First a carotid-subclavian bypass was connected to ensure spinal and brachial perfusion. The thoracic stent graft (60-mm length) was then placed in landing zone 2 without risking consequential damage caused by insufficient blood circulation. Case 3: a 42-year-old patient presented with a high-grade Re-CoA and a subsequent 4.4-cm thoracic aortic aneurysm. We were able to pass the extremely narrow area with a guide wire and to insert and place safely a CP stent using a guide wire with right-brachio-right-femoral pull-through technique. Case 4: a 35-year-old patient who received thoracoabdominal aortic conduit implantation for postductal CoA in 1988, suffered from multiple severe stenoses and calcifications of the conduit, resulting in sudden cardiac arrest with resuscitation. The CoA was successfully treated by percutaneous quadruple-stent implantation which enabled recovery of left ventricular function.

Result: All patients underwent successful therapy by catheter intervention. Image fusion techniques from CT or MR scans were used in all cases. Additionally, MR-T1 mapping and delayed contrast enhancement sequences were applied for tissue characterization and to assess left ventricular remodeling over time. Annual follow-ups showed consistently good results.

Conclusion: Our analysis showed that minimally invasive therapy is a serious option for very complex Re-CoA in ACHD patients, but high-end imaging methods are prerequisite. Compared with surgery the interventional approach implies shorter convalescence and higher patient comfort.

Publication History

Article published online:
21 February 2021