A Case of Successful Bare Metal Stenting for Aortic Coarctation in an Adult
A 47-year-old man presented to our hospital due to sustained headache and uncontrolled hypertension. The patient had a history of hypertension diagnosed approximately 10 years previously. His hypertension was poorly controlled despite a combination of three different antihypertensive agents (candesartan 16 mg DP, amlodipine 5 mg DP and hydrochlorothiazide 12.5 mg DP).\nPhysical examination showed a blood pressure of 140/80 mm Hg in both arms, a heart rate of 69 beats/minute and no audible murmur. There was no significant pathologic finding in the chest radiography. His echocardiogram showed enlarged sinus portion of ascending aorta with moderate aortic regurgitation (grade 3), suspicious of aortic aneurysm, but left ventricular systolic function was well preserved. Due to the significantly enlarged sinus portion of ascending aorta, the patient underwent multislice spiral computed tomography (CT) angiography for evaluation of aorta anatomy. CT angiography showed focal significant stenosis of the descending aorta, just below the left main pulmonary artery level with vigorous collateral blood flow (). Invasive aortography was then performed, which showed severe aortic coarctation distal to the origin of subclavian artery (). According to the quantitative aortography measurements, the coarctation segment was a minimum of 8 mm in diameter and 40 mm in length. The diameters of the thoracic aorta above and below the coarctation segment were 19 and 22 mm, respectively. The patient was then planned for elective percutaneous balloon dilatation with subsequent stent implantation.\nUnder the local anesthesia, bilateral retrograde femoral artery approach was carried out. A 7 Fr arterial sheath was inserted into the right femoral artery and then in sequence a 5 Fr arterial sheath was also inserted into the left femoral artery. After this, a 5 Fr pigtail catheter was placed at the coarctation segment following successful wiring with a 0.035 inch Terumo guidewire (Terumo, Tokyo, Japan). After baseline angiography was done, a pigtail catheter was removed for predilatation. Afterwards, multiple predilatation with an 8×40 mm PowerFlex balloon (Johnson & Johnson, Miami, FL, USA) was applied to the coarctation segment. Additional predilatation with a 10×40 mm PowerFlex balloon was followed sequentially. An aortic stent was successfully deployed using a 22×50 mm self-expandable nitinol stent (Hercules Vascular stent, S&G, Seongnam, Korea) (). Further to this, post-dilatation with a 12×40 mm Ultrathin balloon (Boston Scientific, Natick, MA, USA) was carried out.\nImmediate after the stenting, final aortography revealed adequate patency of the stent in the coarctation segment of the thoracic aorta and showed correct device position without any dissection or perforation, with the diameter of the isthmus increased from 8 to 16 mm ().\nThe patient has been prescribed acetyl salicylic acid 100 mg per day, which was continued until the latest visit. Clinical follow-up was performed at 1, 3 and 6 months after the procedure then continued at 4-month intervals. The patient's hypertension was well controlled using fewer antihypertensive medications on follow-up and his subjective symptoms disappeared shortly after the procedure. To date, the patient has been followed for 12 months in good clinical condition.\nFollow-up multislice spiral CT angiography was performed at six months after the procedure and showed no significant re-stenosis within the stent of coarctation segment. Further, occlusion of abdominal aorta branches, aneurysm formation, or other related complications were not observed. CT angiography also showed tremendously diminished collateral blood flow compared with pre-procedural images ().