 I'm Zvon Mucrasia, I'm a clinical professor of cardiology at Baylor College of Medicine and an international cardiologist at St. Luke's Medical Center and Texas Heart Institute. I'm also chief editor of Texas Heart Institute, the journal and immediate past president of International Society of Endovascular Specialists. The topic of today's presentation is coordination and its management. These are best handled with endovascular therapy. Here are my disclosures. None of them are pertinent to the presentation that I'm going to give now. Now, as far as coordination is concerned and indication and treatment options, the indications for treatment either surgically or endovascularly are decreasing the lumen diameter of more than 50% of the aortic lumen and pressure gradient of more than 20 millimeters of mercury above and below the co-optation. There are numerous treatment options available as far as surgery is concerned, including patch repair, subclavian flap, end-to-end angstromosis and bypass. As far as endovascular approaches are concerned, balloon angioplasty was the first one to be introduced followed by placement of various type of stents and then more recently the use of stengrafts. Now in spite of good outcomes with surgical treatment of co-optations in great majority of patients, there are late complications of the surgical treatment of co-optation that are listed here. Angerisms have been frequently reported after patch repair and also subclavian flap as well as to end-to-end angstromosis and bypasses. The overall aneurysm and pseudo-aneurysm incidence is somewhere in the range of 10% after surgical repair. It is somewhat more common after subclavian flap repair of 17% and the dachron patch repair which ranges in the literature between 5 to 38% and tube graft repair at 6%, but the overall aneurysm rupture rate which is of great concern has been reported to occur in about 7% of patients. So what are the advantages of endovascular approaches to treatment of co-optation? Number one, the endovascular technique is less invasive. It offers less complications. It offers early recovery with excellent procedural and long-term results. It can be used in the form of PTA balloon or Palmas Excel stents that are listed here or stengrafts such as ICAST or other ones that have been recently approved for this indication. We can see the images of all those technologies that have been used for treatment of co-optation using endovascular approach. So what are the procedural results and acute complications in stenting of native and recurrent correction of deorta in patients over four years of age? And here is this multi-institutional study that I would like to share with you. It is a retrospective review of a study carried on in 70 institutions from 1989 to 2005 in 565 procedures in 155 patients. The median age range was 15 years, 52% had a native co-optation and the 40% had recurrent surgical co-optation and recurrent intervention was reported in 7% of patients. Interestingly enough, the procedural success rate was close to 98%. The aortic wall complications such as dissection or pseudo-annuism was reported in 3.9% of patients. Now we can see the literature review related to endovascular co-optation repair from various centers and various studies and we can see that various type of devices have been used from a Palma stent to a newer generation either balloon expandable or self-expandable stent. And the follow-up ranged here between 18 months to 60 months and the age also ranged between 19 years to 46 years. What's also interesting is the technical success rate was very high in most of the studies close to 100%. And we can see as far as pressure gradients from pre-op to post-op is concerned we can see dramatic reduction in the pressure gradients typically from 50 millimeters of mercury or higher to the range of 6 to 16 millimeters of mercury after completion of the procedure. I would like to share with you a few of the examples in patients that underwent endovascular intervention for complex procedures with co-optation. Here is one patient 34 years of age with the exertional shortness of breath and malignant hypertension and as we can see elevated blood pressure in both arms this patient had a super tight quartation that they show in the middle panel with a blue arrow and on the right hand side we can see the eyewitness image that shows severe narrowing with a luminal diameter roughly of 4 to 5 millimeters. This procedure was performed by a percutaneous approach on the local anesthesia with such immediate closure device in a pre-closed fashion with a long sheet. There was a severe gradient of 80 millimeters of mercury across the quartation. In the left-hand panel we can see the indentation of the balloon during the dilatation. This balloon was 15 by 40 millimeters non-compliant balloon and then we can see post-40-10 Palmas Excel stand placement, a beautiful result without any evidence of a complication and alleviation relief of the gradient from 80 millimeters of mercury to zero millimeters of mercury at the completion of the procedure. We can also see at the follow-up at two years excellent result on the CTA with 3D reconstruction of this particular intervention. Here's another patient, 32-year-old, which has pain and decreased exercise capacity and an underwent PDA and a quartation repair at the age of three and a half months with a background graft. We can see here on CT pseudo-annuism formation and calcification in the pseudo-annuism with super tight quartation. We can see in this particular scenario after balloon angioplasty and placement of the stand graft that measured 24 millimeters in diameter and 160 millimeters in length, excellent results and alleviation of the gradient. We prefer in patients with pseudo-annuism to use the stand grafts rather than playing all balloons or bare metal stands to prevent rupture and serious complications. Here's another patient of ours that had also as a child two graft placement for treatment of quartation, the patient developed pseudo-annuism and this was treated with a combination of different type of stand grafts to resolve this problem and placement of the endovascular coils and we can see a long-term follow-up at 12-year follow-up excellent result without any evidence of endo-leak or any other complications. We reviewed our institution, our experiences with treatment of quartation either with surgical approach or endovascular approach and we can see that 943 patients are included in this particular study and we can see that the complication such as aneurysm occurred in 5.8% of patients. We can see that the residual quartation was present or re-quarctation in 40% of those patients and then we can see that the surgery was performed roughly in 80% of patients and in about 21% of patients endovascular approach was selected. We can see that 30-day mortality was 1.9% with surgery but there were neurological events in 5.7% of patients including paraparesis in almost 2% of patients, respiratory problems, need for tracheostomy, acute renal insufficiency, vocal cord paralysis in 21% of patients and also re-operation for bleeding. Now when we compare this in 11 patients that underwent endovascular repair with various type of a stand grafts, we can see that there was a zero morbidity, zero mortality and zero need for re-intervention. So what are the advantages of endovascular treatment of quartation? Majority of patients can be treated with good results. This particular approach avoids extensive thoracic surgery and other aggressive measures inherent with surgery. Re-quarctation, aneurysms and pseudo-aneurysms for surgery can be successfully treated with various commercially available stand grafts. In our personal experience, local anesthesia, percutaneous approach, outpatient procedure offers lower cost and offers good long-term outcomes. Balloon expandable stents or stand grafts are preferable techniques to plane all balloon angioplasty and redo interventions are possible at low risk and good long-term results. Thank you very much for your attention.