Benefits of surgical repair of coarctation of the aorta in patients older than 50 years

doi:10.1016/S0003-4975(01)03094-6

The Annals of Thoracic Surgery

Volume 72, Issue 6, December 2001, Pages 2060-2064

https://doi.org/10.1016/S0003-4975(01)03094-6 Get rights and content

Abstract

Background. Most patients with unrepaired coarctation of the aorta die before the age of 50 years. In patients who present at an older age, the indications for surgical treatment are controversial because the benefits of operating are unclear.

Methods. At follow-up investigation from 0.5 to 11.5 years (mean, 4 years) after primary surgical correction of coarctation in 15 patients aged 50 to 63 years (mean, 54 years), we analyzed the preoperative and postoperative complications, symptoms, need for antihypertensive drugs, and blood pressure at rest and during exercise.

Results. Preoperatively no patient had normal blood pressure at rest despite combined antihypertensive medication. There was no significant mortality or morbidity after repair. At follow-up examination only 3 patients had at rest mild hypertension, the other 12 patients were normotensive. Of the 11 tested patients, 8 displayed systolic arterial hypertension during exercise.

Conclusions. Surgical correction of coarctation can be performed after the age of 50 years with low surgical risk. Operation reduces systolic hypertension at rest and permits more effective medical treatment. Despite persistence of the hypertension during exercise, symptomatic improvement occurs in most patients.

Section snippets

Patients and methods

From April 1988 to August 2000, 15 patients aged 50 to 63 years (mean, 54 years), underwent primary surgical repair of coarctation of the aorta in our institution. Diagnosis of the coarctation was established before 10 years of age in 5 patients, between 11 and 30 years in 5 patients, between 31 and 50 years in 2 patients, and after 50 years of age in 3. Nine patients (60%) had associated cardiac diseases. The clinical data of the patients are presented in Table 1. Before the operation coronary

Results

Preoperatively all patients had exhibited arterial hypertension at rest. Medical control of hypertension was not possible despite triple or even quadruple antihypertensive drug regimens applied in most patients. Only 1 patient received no preoperative antihypertensive medication. All other patients were administered antihypertensive drugs to prevent cerebrovascular insults and cardiac events from extreme hypertension. The dosage of the medication was adjusted so that severe peripheral

Comment

This study contains the largest patient group that has undergone repair of coarctation of the aorta at more than 50 years of age to be reported in the literature to date. Other reports with regard to this age group are only casuistic 4, 5 or only a few patients older than 50 years are included in the reports on coarctation repair in adults 7, 8, 9, 10, 11. It is well known that, to avoid late hypertension and to prevent recoarctation, the optimal age for elective aortic coarctation repair is

Acknowledgements

The authors thank Anne M. Gale for editorial assistance, Julia Stein for statistical advice, and Reinhold Giering-Jaensch for providing the illustration.

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If the condition is left untreated, most patients die by the fifth decade of life.1 Therefore, only few cases have been reported that were first diagnosed as untreated coarctation at a late age (>60-70 years), and we still do not have an exact consensus on which treatment is most beneficial for these patients.2 In this case, the left subclavian artery makes a Kommerell's diverticulum and the right one directly connects to the coarctation site.
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La coarctation de l’aorte thoracique descendante est une anomalie vasculaire rare. Son étiologie est controversée. Elle se manifeste le plus souvent par une hypertension artérielle sévère. Plus rarement, elle peut se traduire par une claudication intermittente. En dépit de sa complexité, le traitement chirurgical demeure le traitement de choix des coarctations longues et offre de bons résultats à court et à long termes.
Nous rapportons trois cas de coarctation aortique descendante opérés sur une période de deux ans (janvier 2012–décembre 2013). Le suivi comportait une surveillance de la pression artérielle et des angioscanners aortiques.
L’âge moyen des patientes était de 19 ans et le suivi moyen était de 16 mois. L’hypertension artérielle était la présentation clinique habituelle. Le diagnostic a été posé par l’angiographie. Deux cas ont été traités chirurgicalement par un pontage aorto-aortique et un cas par un pontage sous-clavio-aortique. Les suites opératoires ont été simples. La pression artérielle a été contrôlée sous deux antihypertenseurs et les signes fonctionnels ont disparu chez toutes les patientes.
La coarctation de l’aorte thoracique descendante est une entité rare. L’étiologie peut être congénitale ou acquise d’origine inflammatoire. En l’absence de traitement, l’évolution est souvent fatale du fait des complications de l’hypertension artérielle. Le traitement chirurgical s’impose quasi-constamment. Il offre de bons résultats et fait appel le plus souvent à un pontage aorto-aortique associée ou non à une revascularisation rénale.
Coarctation of the descending thoracic aorta is uncommon, with controversial etiology. Usually, severe hypertension is the main symptom; lower extremity claudication is less often found. Surgical management remains the standard for long coarctation and provides good results.
We report three cases of coarctation of the descending aorta operated at our department of cardiovascular surgery of Hospital La Rabta between January 2012 and December 2013.
The median age was 19 years and the median follow-up was 16 months. Hypertension was the most common clinical manifestation. The diagnosis was made by computed tomography angiography. Two cases were treated by an aorto-aortic bypass and one by subclavian-descending aorta bypass. Recovery was excellent, with a decrease in antihypertensive medications (four to two) and restoration of all distal pulses.
Middle aortic coarctation is a rare entity. Etiologies include congenital, acquired, inflammatory and infectious causes. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Depending on technical considerations, open surgical bypass remains the standard repair for mid-aortic syndrome.
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Roselli compared 60 endovascular repairs with 40 open repairs with a variety of techniques including two REE, two patch aortoplasty, 16 RIPG, and 20 extra-anatomic repairs.17 Like other authors,15-19 we report low perioperative major morbidity and no repair-related mortality. Our preferred technique of open repair in adults, especially with aneurysm, is with RIPG (93%).
We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique.
We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed.
Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment.
Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.
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Coarctation of the Aorta Stent Trial (COAST): Study design and rationale
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We anticipate that the proportion of patients experiencing paradoxical hypertension will be lower (superior) for those treated with the CP stent. For surgical patients, this value is estimated at 84% based on surgical reviews.17,23,24 For patients treated with the CP stent, the proportion is assumed to be no greater than 25%.
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The COAST study is a prospective, multicenter, single-arm clinical study. The population includes patients with native or recurrent CoA. Four primary outcome variables were defined. For each variable, the stent will be compared to performance guidelines derived from surgical experience. The first efficacy outcome is reduction in arm-leg systolic blood pressure gradient, and the second is reduction in hospital length of stay. Safety outcomes include the following: the occurrence of any serious or somewhat serious adverse event attributed to the stent or implantation procedure and the occurrence of postprocedure paradoxical hypertension. A total of 105 patients treated with the CP stent will be enrolled.
To ascertain the effectiveness and safety of an interventional device, randomized controlled trials have been offered as the criterion standard. However, these trials are not well suited to study rare conditions such as CoA, especially once the therapy in question has received acceptance within the medical community. New clinical trial and statistical approaches are needed to evaluate such therapies. The COAST study is an example of this kind of innovative trial design.
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Original article: cardiovascularBenefits of surgical repair of coarctation of the aorta in patients older than 50 years

Abstract

Section snippets

Patients and methods

Results

Comment

Acknowledgements

J Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Coarctation of the aorta in adult patients

J Thorac Cardiocasv Surg

Natural history of coarctation of the aorta

Br Heart J

Coarctation of the aorta presenting in a 79-year-old male

Thorac Cardiovasc Surg

Original article: cardiovascular
Benefits of surgical repair of coarctation of the aorta in patients older than 50 years