Stenting complex aortic arch obstructions.

OBJECTIVE

To present our institutional experience of endovascular stent therapy in patients with complex aortic arch lesions.

BACKGROUND

The management of aortic arch obstructions is complex and many physicians are either reluctant to treat mild-moderate aortic arch lesions associated with systemic hypertension or instead refer to high-risk surgical alternatives. Reported data on transcatheter stent therapy of complex aortic arch lesions are scarce.

METHODS

Between October 2002 and November 2006, 40patients (pts) had complex aortic arch lesions treated with stent implantation in 42 procedures (proc). Aortic arch hypoplasia was present in 30/42 proc (71.4%). The median age was 10 year (16 days - 37 years). In 40/42 proc (95.2%) patients had previous transcatheter or surgical aortic arch interventions.

RESULTS

Procedural success in achieving a peak systolic gradient reduction to <or=10 mm Hg with an improvement in the diameter to >or=90% of the "normal" adjacent aortic arch was achieved in 38/42 proc (90.5%). The diameter of the arch obstruction increased from a median of 7.55 mm to a median of 14 mm (P < 0.0001) and the peak systolic gradient was reduced from a median of 23 mm Hg to a median of 2 mm Hg (P < 0.0001). Arch vessels were crossed in 31/42 proc (73.8%). Periprocedural adverse events were encountered in 13/42 proc (30.9%), predominately in patients with a weight below 10 kg or univentricular physiology. The median follow-up was 1 year (32 days - 3.8 years). The incidence of systemic hypertension was significantly reduced from 22/42 (52.4%) before the procedure to 6/39 (15.4%) at the most recent follow-up (P = 0.0005). CT or MRI evaluations were performed in 18 pts, documenting all crossed arch vessels to appear patent.

CONCLUSIONS

Stenting of complex aortic arch lesions can be performed safely and effectively with excellent, immediate, and midterm results. Patients with a weight below 10 kg or after Hybrid stage I palliation are at increased risk of adverse events. Stents can be placed across major arch vessels without compromising distal perfusion in otherwise normal vasculature.