Alcibar J, Peña N, Oñate A, Cabrera A, Galdeano JM, Pastor E, Inguanzo R, Vitoria Y, Gómez S, Arana JI, Barrenechea JI
Sección de Hemodinámica. Servicio de Cardiología. aSección de Cardiología Pediátrica. Hospital de Cruces. Vizcaya.
Rev Esp Cardiol. 2000 Jun;52(6):797-804.
The use of balloon-expandable stents provides an effective alternative therapy in patients with stenotic lesions in congenital heart disease. Stents implantation has served to improve the results and to reduce complications of balloon angioplasty for coarctation and recoarctation of the aorta. AIM: We report our results after primary stents implantation for coarctation and recoarctation of the aorta. PATIENTS AND METHODS: Balloon-expandable stents were implanted in 14 patients (mean age 20 +/- 12 years) with coarctation of the aorta (11 native and 3 postoperative); 2 patients had associated malformations. The morphology varied: 10 resembled a located-diaphragm (one of them with moderate arch hypoplasia); 2 had distorted coarctation and 2 had a complete aortal obstruction. Five patients were hypertensive and 1 had cardiogenic shock and severe arrhythmias which did not respond to intensive medical therapy. In all cases 14 Palmaz stents (7 P308 and 7 P4014) were implanted with the primary technique through a Mullin's sheath. The balloon-to-descending aorta diameter ratio, measured at the level of the diaphragm, was 1. A special technique was carried out in the 2 cases with complete aortal obstruction. RESULTS: The procedure was effective in all 14 cases. The coarctation diameter increased from 4 +/- 2 to 15 +/- 2 mm (p < 0.0001) and transcoarctation systolic pressure gradient decreased from 43 +/- 19 to 2 +/- 2 mmHg (p < 0.0001). The ratio of the coarctation to descending aorta diameter measured at the level of the diaphragma increased from 0.3 +/- 0.1 to 0.95 +/- 0.05 (p < 0.001). At 19 +/- 8 months follow up, all patients showed sustained clinical improvement. The patient with complete aortal obstruction experienced a dramatic improvement, but she died from a sudden cardiac event 22 months after the procedure. At angiographic follow up in 7 patients, 1 year after implantation, no recoarctation was observed with secondary vessels patent, and absence of restenosis. CONCLUSIONS: a) Percutaneous endovascular stents implantation in coarctation and recoarctation of the aorta may become an effective treatment modality in the older child, adolescent and adults; b) stents are particulary attractive in those patients with a more complex anatomy and higher surgical risk; c) primary stenting is expected to have a lower rate of complications, and d) we describe a special technique with a right femoral-left humeral arterial circuit that is successfully applied to patients with complete aortal obstruction.
对于先天性心脏病狭窄病变患者，使用球囊扩张支架可提供一种有效的替代治疗方法。支架植入有助于改善主动脉缩窄和再缩窄的球囊血管成形术的效果并减少并发症。目的：我们报告主动脉缩窄和再缩窄初次支架植入后的结果。患者和方法：14例患者（平均年龄20±12岁）植入球囊扩张支架，其中11例为原发性主动脉缩窄，3例为术后再缩窄；2例患者伴有其他畸形。形态各异：10例类似局限性隔膜（其中1例伴有中度主动脉弓发育不全）；2例为扭曲型缩窄，2例为完全性主动脉梗阻。5例患者有高血压，1例有心源性休克和严重心律失常，强化药物治疗无效。所有病例均通过Mullin鞘管采用初次技术植入14枚Palmaz支架（7枚P308和7枚P4014）。在隔膜水平测量的球囊与降主动脉直径比为1。对2例完全性主动脉梗阻患者采用了特殊技术。结果：该手术在所有14例患者中均有效。缩窄处直径从4±2mm增加到15±2mm（p<0.0001），缩窄处收缩期压力阶差从43±19mmHg降至2±2mmHg（p<0.0001）。在隔膜水平测量的缩窄处与降主动脉直径比从0.3±0.1增加到0.95±0.05（p<0.001）。随访19±8个月时，所有患者临床持续改善。完全性主动脉梗阻患者病情显著改善，但术后22个月死于心脏突发事件。7例患者术后1年血管造影随访，未观察到再缩窄，分支血管通畅，无再狭窄。结论：a）经皮血管内支架植入治疗主动脉缩窄和再缩窄可能成为大龄儿童、青少年和成人的一种有效治疗方式；b）对于解剖结构更复杂、手术风险更高的患者，支架尤其具有吸引力；c）初次支架植入预计并发症发生率较低；d）我们描述了一种采用右股动脉-左肱动脉回路的特殊技术，该技术已成功应用于完全性主动脉梗阻患者。
