Percutaneous Intervention for totally Occluded Coarctation Of Aorta. John Jose, Vipin Kumar, Ommen K George Dept Of Cardiology
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1 Percutaneous Intervention for totally Occluded Coarctation Of Aorta John Jose, Vipin Kumar, Ommen K George Dept Of Cardiology
2 Background Coarctation of aorta (CoA) forms 5-7% of congenital heart diseases Totally occluded CoA is very rare Surgical repair is the standard treatment Few cases exist in the literature concerning angioplasty & stenting for totally occluded CoA Percutaneous procedures successful in analogous situations: pulmonary valve atresia, IVC webs
3 Clinical details History 27 year old female with secondary hypertension Referral after failed coarctoplasty attempt elsewhere Turner phenotype Findings Upper limb BP: 170/80 mmhg; feeble lower limb pulses CVS: Ejection click +
4 Investigations ECG Sinus rhythm, Left ventricular hypertrophy Chest Radiograph Echo Bicuspid aortic Valve Normal LV Function
5 Aortogram Total cutoff of descending thoracic aorta just distal to the left subclavian artery origin Image Arch angiogram (LAO 45 0 ) (trans brachial access) Descending Thoracic Aortogram (femoral access) Retrograde & Antegrade Simultaneous Angiogram (6F femoral & right brachial access)
6 Diagnosis & Management Options Congenital Acyanotic Heart disease Coarctation of aorta totally occluded Bicuspid Aortic valve Management Options Interventional Surgical
7 Percutaneous Intervention: Materials Sheath: 6F 12F short sheath (femoral) Guide wires: Conquest Pro, Miracle 12 coronary wires (Asahi Intecc) hydrophilic wire (Terumo GlideTechnology ) Amplatz Super Stiff Guide Wire (Boston Scientific) Stent: P5014 Palmaz stent (Cordis Corporation, a Johnson & Johnson company; Warren, NJ) Catheters: 5F Glide Cath (Terumo ), 6F pig tail, Judkin s right 4 (Cordis) Balloons: Coronary balloons: 1x10mm & 2x12 mm Perpheral balloons: - 4x20mm, 6x20mm ATB (Cook Medical) -14X40mm Maxi LD (Cordis)
8 Procedure Steps :Crossing the lesion Miracle and conquest pro coronary wires, soft end Fail LAO hydrophilic wire Fail Back (hard) end of conquest pro wire Success Puncture assisted by orthogonal views & repeated angio above occlusion site
9 Procedure Steps: Initial dilatation Serially dilated with a 1x10 mm & 2x12mm coronary balloon at 14atm Coronary wire exchanged with a hydrophilic Glide wire Glide catheter taken over the hydrophilic wire Amplatz Super Stiff Wire exchange LAO 45 0 Image
10 Procedure Steps: Balloon dilatation Dilatation with 4x20 mm balloon Dilatation with 6x20 mm balloon LAO 45 0
11 Procedure Steps: Stenting P5014 Palmaz stent mounted on a 14x40 mm Maxi LD balloon, deployed at 8 atm LAO 45 0
12 Post stenting Aortogram Region Pre Post Ascending Aorta 174/92 142/82 Femoral Artery 97/85 135/80 LAO 45 0
13 Complications & follow up No complications during or after procedure Asymptomatic on follow up Planned re-intervention in June 2013
14 Key learning points Percutaneous intervention for total occlusion CoA/ local aortic atresia feasible if 1. Appropriate case selection 2. Appropriate puncture material 3. Adequate care during puncture
15 Learning points 1. Patient selection for percutaneous treatment Fig. A CoA Fig. B Complete obliteration Fig. C Segmental atresia Fig.D Absence of part of aortic arch Courtesy : G. Joseph et al, CMCH Vellore
16 Learning points 2. Instruments for puncturing the atretic segment Coronary wires, soft end Fail hydrophilic wire Fail Back (hard) end of coronary CTO wires Fail FIRST REPORT Brockenbrough needle Fail PowerWire TM Radiofrequency Guidewire (Baylis)
17 Learning points 3. Approach during the puncture Monitor direction of movement of the puncturing instrument in two orthogonal views Repeated contrast injections from above
18 Challenges & limitations Immediate complication: Risk of aortic perforation & extravastion Aortic rupture Dissection Long term complications:? aneurysms
19 Conclusion & Take Home Message Percutaneous intervention is feasible in certain cases of totally occluded CoA Recanalisation, balloon angioplasty & stenting can be safely and successfully performed proper case selection, appropriate precautions Cheap & safe alternative to surgery
20 Acknowledgements Sincere Thanks Dr. George Joseph, Prof & Head, Dept Of Cardiology-I, CMCH, Vellore Dr. Purendra Pati, Prof, Dept Of Cardiology-II, CMCH, Vellore Conflict Of Interest : None Funding: None
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