Management of Coarctation of Aorta in an Adult
Coarctation of the aorta is a congenital condition that can persist into adult age. In an adult, the indications for revascularizing coarctation of aorta include: 1) uncontrolled hypertension; 2) significant claudication; and 3) significant gradient >20 mm Hg across the coarctation.
Endovascular stenting of the coarctation is the procedure of choice due to its low morbidity and mortality. A Palmaz hand mounted stent is deployed across the coarctation. The deployment has to be at low pressures and not more than 4 atm. High pressure and rapid inflation can result in stent migration, balloon rupture, media tear, injury, and subsequent aneurysm formation. Risk of complete aortic rupture and exsanguinations is also a devastating complication of balloon dilatation or stenting of coarctation. The balloon diameter chosen for coarctation should not be more than 3 times the diameter of the narrow portion of the coarctation. The maximum size of the balloon should be less than the diameter of the aorta at the level of diaphragm. Placement of covered stents across the coarctation can be safe and effective. However, dedicated covered stents for coarctation are not readily available. The stent is usually mounted on balloons of diameters 14-20 mm and will necessitate use of large bore sheaths >10 Fr. Vascular access complications are also common due to the large size sheaths used.