 Welcome to Texas Heart Institute Educational Programs on Innovative Technologies and Techniques. My name is Von Merkrazier, I'm an Interventional Cardiologist at Texas Heart Institute and Baylor CHI Medical Center. The topic today is Quarctation and its management. These are best handled with endovascular therapy. Quarctation treatment, as far as indications and options are concerned, there are particular indications that are necessary to consider any kind of intervention on patients with this condition. The most important one is decreasing the luminal diameter of more than 50% at the quarktation site and a pressure gradient across the quarktation of more than 20 millimeters of mercury. There are several options obviously available as far as treatments are concerned and one is surgery with a variety of options such as patch repair, subclavian flap, end to end anastomosis with suture based technique and bypass with a variety of conduits. Endovascular approach includes balloon angioplasty, the use of various kinds of stents and stain grafts. I would like to share with you some of the complications, particularly late complications after surgical treatment of quarktation. Aneurysms have been frequently reported after patch repair, but also after subclavian flap and end to end anastomosis and also bypasses. As we can see here on this image, a formation of a pseudo-aneurysm at the site of previous surgical repair. The overall incidence of aneurysms and pseudo-aneurysms after surgical repair is somewhere in the range of 10%. After subclavian flap repair is slightly higher, it's 17%. After that chrome patch repair is even higher and it ranges in the literature between 5% to 38%. And after the use of tube graft repair somewhere in the range of 6%. What's very important is the overall aneurysm rupture risk is roughly at 7% in the literature. There are numerous advantages of endovascular techniques for quarktation repair. Number one, it's a less invasive procedure. It has less complications. It offers early recovery with excellent procedural and also long-term results. There are a variety of techniques available. One of the older ones is plain oil balloon angioplasty, which is nowadays rarely used and is typically used in infants and children. But more frequently now we're using stents of various kind. One of the older ones is Palmas XL stents that are either 30 mm in length or 40 mm in length or 50 mm in length and they can dilate from 10 mm all the way up to 30 mm in diameter. And more recently there are a variety of stem grafts available. One of the earliest one was ICAST, but now there are several other ones which have balloon expandable but also we have several self-expanding stem grafts that are being used for this particular condition. Forbes and co-workers reported in the catheterization and cardiovascular intervention in 2007 their multi-institutional study on procedural results and acute complications instanting native and recurrent co-arctation of the aorta in patients over four years of age. This was a retrospective review from 1989 to 2005 that involved 17 institutions. 565 procedures were performed in 555 patients median age of 15 years. The procedures were performed in native co-arctation without previous surgery or intervention in 52% of patients. In recurrent surgical co-arctation about 40% of patients and recurrent post-intervention co-arctations in 7% of patients. What is important is that their procedural success rate was close to 98%. However, aortic wall complications occurred in 3.9% of patients that included either dissection or perforation with extravisation. Here is a literature review related to endovascular co-arctation repair from several studies. The first one by a thanopolis that was published in the Journal of American College of Cardiology in 2008 included 40 sick patients with a mean age of 33 years and a follow-up in months was 60 months. This particular study reported on the use of Palma's stent for treatment of co-arctation. Their technical success was 100% and we can see that the gradient before the interaction was 58 mmHg and it was reduced to 6.5 mmHg after the successful procedure. The other reports that are listed here all included the use of a variety of stent graphs such as Optomet or Sinus aorta stent, endofint stent graph and talent and valiant stent graphs. You can see again the technical success rate is very high. It was higher in Schnabel's publication and Bota's publication than in Haji Zainali publication. Again, as we can see, there is a dramatic reduction in the gradient after the use of stent graphs for co-arctation repair. I would like to share with you some of our personal experience related to endovascular interactions for treatment of co-arctation. The first case that I would like to share with you was a 34-year-old male with exertional shortness of breath and malignant hypertension. His physical examination revealed the elevated blood pressure in the left and right arm of 180 over 90 mmHg. With excellent brachial pulses but no femoral or dazalis pedis or posterior tibial pulses. As we can see here on the left side images, there was a very severe co-arctation present after the origin of the left subclavian artery. And on the right-sided image, we can see the intravascular ultrasound image that shows a lot of calcium and also fibrosis and the severe narrowing at the site of the co-arctation prior to the intervention. This information showed the intramational procedure. As we can see here, the approach was a percutaneous femoral artery access. We pre-closed the access side with 10 French prostarexcel and then advanced the 11 French sheath at 75 cm long and measured the gradient across the co-arctation which was 79 mmHg. We then performed balloon angioplasty with 15 mmHg in diameter and 40 mmHg non-compliant balloon. And then deployed a Palmas excelle stent that was 40 mmHg to 16 mmHg as we can see here and we achieved the total evaluation of the gradient that was 79 mmHg before the intervention to no gradient at the end of the procedure. And the procedure was successful without complications. The femoral artery was repaired at the end of the procedure and the patient was discharged from the hospital on postoperative day one. A two-year follow-up on the right-hand side, we can see a 3D CTA image with excellent results and that this patient continued to do well and actually his arterial hypertension was significantly improved on long-term follow-up. Case number two that I would like to share with you is a patient that had developed pseudo-annuers and post-surgical quarktation repair as we can see here on the CT images showing very narrow area at the site of residual quarktation and also presence of a pseudo-annuers. This was a 32-year-old male that had a repair at an early age elsewhere and this procedure was done with a Dachron graft material. We can see during the intervention the angiogram in the middle frame shows the presence of a pseudo-annuers and very narrowed segment where quarktation occurred. There was a severe gradient of 60 mmHg across the quarktation. And then on the right-hand side, we can see that this particular patient was treated with thoracic stenograph that measured 24 mmHg in diameter, approximately in distally, and it was 160 mmHg in length. The gradient was completely abolished and there was no evidence of any endolique or flow to the pseudo-annuers. This patient was also discharged on postoperative day number one without complications and he continued to do well on a long-term follow-up. The third patient that I would like to share with you is more complex than the other previously discussed patients. This patient was a 30-plus-year-old patient that was referred to us from another country and he had a quarktation repair surgically elsewhere at the age of six. We can see here on the CT images and also on the schematic rendering that this procedure was done surgically with a small 10 mmHg graft that the hist in the distal segment and there was a formation of a large pseudo-annuers in the distal part distally to the quarktation. This procedure was performed again via percutaneous approach in local anesthesia using a suture-mediated closure device. We used an anurex limb for this particular problem and also Gore tag stand graft that were overlapped in the existing tube graft to resolve and address the problem of pseudo-annuers and also the section. He also had a coil embolization of that pseudo-annuers and as we can see the final angiogram completion angiogram shows excellent result and no evidence of endolique. The patient was discharged the following day and here we can see a 12-year follow-up CTA again with excellent results and the patient is asymptomatic and there is no evidence of any endolique at the previous pseudo-annuers. We have also at our institution looked at our long-term experience as far as quarktation repair is concerned where more than 900 quarktations were performed over longer period of time and we can see here that 55 patients developed aneurysms after surgical repair at long-term follow-up. We can see that quarktation was still present in a significant number of patients as shown here and required not only treatment of quarktation but also treatment of formation of the aneurysm. Here we can see here that patients underwent open surgical repair in almost 80% of cases and 11 patients or 21% of patients had endovascular repair. Now as far as the results are concerned 30-day mortality was close to 2% with surgical repair and neurological deficit occurred in 5.7% of patients and as we can see a peresis occurred in 1.9% of patients. Significant number of patients also had respiratory complications such as 11.3% that required prolonged ventilation and 3.8% of patients required tracheostomy. Acute renal insufficiency was present in 5.7% of patients and vocal cord paralysis occurred in almost 21% of patients and 7.5% of patients required re-operation for bleeding and the median hospital stay was 7 days with a range between 6 to 9 days. We compare this with our experience in this particular population, 11 patients that were treated via endovascular approach. We can see that the mean range age was 39%, length of follow-up was 40 months and devices that we use were TAG thoracic by Gore and talent by Metronic. There were no morbidities occurring in this particular group of patients, zero mortality and zero need for re-intervention. So on the basis of our experience and experience of others, we can see significant advantages of endovascular treatment of coarctation. Majority of patients can be treated with good immediate and long-term results. This particular approach avoids extensive thoracic surgery and other aggressive measures that are inherent with surgery. Re-coarctation, aneurysms and pseudo-aneurysms can be successfully treated with various commercially available stem grafts. Local anesthesia, percutaneous approach and outpatient procedure lowers cost and offers good long-term results. Balloon expandable stems or stem grafts are preferable to the technique of plain old balloon angioplasty. Re-do intervention is also possible at low risk and good results whenever this is necessary. Thank you very much for your attention.