Rao P S, Galal O, Smith P A, Wilson A D
Department of Pediatrics, University of Wisconsin Medical School, Madison.
J Am Coll Cardiol. 1996 Feb;27(2):462-70. doi: 10.1016/0735-1097(95)00479-3.
To evaluate the usefulness of balloon angioplasty for relief of native aortic coarctation, we reviewed our experience with this procedure, with special emphasis on follow-up results.
Controversy exists with regard to the role of balloon angioplasty in the treatment of native aortic coarctation.
During an 8.7-year period ending September 1993, 67 neonates, infants and children underwent balloon angioplasty for native aortic coarctation. A retrospective review of this experience with emphasis on long-term follow-up forms the basis of this study.
Balloon angioplasty produced a reduction in the peak-to-peak coarctation gradient from 46 +/- 17 (mean +/- SD) to 11 +/- 9 mm Hg (p < 0.001). No patient required immediate surgical intervention. At intermediate-term follow-up (14 +/- 11 months), catheterization (58 patients) and blood pressure (2 patients) data revealed a residual gradient of 16 +/- 15 mm Hg (p > 0.1). When individual results were scrutinized, 15 (25%) of 60 had recoarctation, defined as peak gradient > 20 mm Hg. Recoarctation was higher (p < 0.01) in neonates (5 [83%] of 6) and infants (7 [39%] of 18) than in children (3 [8%] of 36), respectively. Two infants in our early experience had surgical resection with excellent results. Three patients had no discrete narrowing but had normal arm blood pressure and had no intervention. The remaining 10 patients had repeat balloon angioplasty with reduction in peak gradient from 52 +/- 13 to 9 +/= 8 mm Hg (p < 0.001). Reexamination 31 +/- 18 months after repeat angioplasty revealed a residual gradient of 3 to 19 mm Hg (mean 11 +/- 6). Three (5%) of 58 patients who underwent follow-up angiography developed an aneurysm. Detailed evaluation of the femoral artery performed in 51 (88%) of 58 patients at follow-up catheterization revealed patency of the femoral artery in 44 (86%) of 51 patients. Femoral artery occlusion, complete in three (6%) and partial in four (8%), was observed, but all had excellent collateral flow. Blood pressure, echocardiography-Doppler ultrasound and repeat angiographic or magnetic resonance imaging data 5 to 9 years after angioplasty revealed no new aneurysms and minimal (2%) late recoarctation.
On the basis of these data, it is concluded that balloon angioplasty is safe and effective in the treatment of native aortic coarctation; significant incidence of recoarctation is seen in neonates and infants; repeat balloon angioplasty for recoarctation is feasible and effective; and the time has come to consider balloon angioplasty as a therapeutic procedure of choice for the treatment of native aortic coarctation.
为评估球囊血管成形术对原发性主动脉缩窄的缓解作用，我们回顾了我们在该手术方面的经验，特别强调随访结果。
关于球囊血管成形术在原发性主动脉缩窄治疗中的作用存在争议。
在截至1993年9月的8.7年期间，67例新生儿、婴儿和儿童接受了原发性主动脉缩窄的球囊血管成形术。对这一经验进行回顾性分析，重点是长期随访，构成了本研究的基础。
球囊血管成形术使缩窄处的峰峰压差从46±17（均值±标准差）降至11±9 mmHg（p<0.001）。没有患者需要立即进行手术干预。在中期随访（14±11个月）时，心导管检查（58例患者）和血压（2例患者）数据显示残余压差为16±15 mmHg（p>0.1）。当仔细分析个体结果时，60例中有15例（25%）出现再缩窄，定义为峰压差>20 mmHg。新生儿（6例中的5例[83%]）和婴儿（18例中的7例[39%]）的再缩窄发生率高于儿童（36例中的3例[8%]）（p<0.01）。在我们早期的经验中，有2例婴儿接受了手术切除，效果良好。3例患者没有明显狭窄，但手臂血压正常，未进行干预。其余10例患者接受了重复球囊血管成形术，峰压差从52±13降至9±8 mmHg（p<0.001）。重复血管成形术后31±18个月复查显示残余压差为3至19 mmHg（平均11±6）。58例接受随访血管造影的患者中有3例（5%）出现动脉瘤。在58例患者随访心导管检查时，对51例（88%）患者的股动脉进行了详细评估，发现51例患者中有44例（86%）股动脉通畅。观察到股动脉闭塞，3例（6%）完全闭塞，4例（8%）部分闭塞，但所有患者的侧支循环均良好。血管成形术后5至9年的血压、超声心动图 - 多普勒超声以及重复血管造影或磁共振成像数据显示没有新的动脉瘤，晚期再缩窄极少（2%）。
基于这些数据，得出结论：球囊血管成形术治疗原发性主动脉缩窄安全有效；新生儿和婴儿中再缩窄的发生率较高；重复球囊血管成形术治疗再缩窄可行且有效；现在是时候将球囊血管成形术视为原发性主动脉缩窄治疗的首选治疗方法了。
