What is the best treatment for native coarctation of the aorta?

Introduction:

Isolated native coarctation of the aorta (CoA) affects 1 in every 1800 infants born in the United States each year. Currently there are three primary treatment options: balloon angioplasty (BA), stent, and surgical repair. Since the approval of stent therapy for CoA in the 1990s, there has been a debate on which of the three treatment modalities is superior. Data has often been limited due to the lack of short and intermediate follow-up. The purpose of our study is to compare the efficacy and safety of stent, BA and surgical therapy in patients (pts) weighing more than 10kg over a 10 year period.

Methods:

We conducted a multi-center prospective observational study. Hemodynamics, imaging studies, and complications were recorded. Measurements were collected at baseline, acute, short-term (3-18 months) and intermediate (>18 months) follow-up.

Results:

A total of 673 patients from 42 institutions undergoing treatment of their native CoA of the aorta were enrolled in the study between June 2002 and March 2019. Patients were divided into three groups; 453 underwent stent, 97 underwent BA and 123 underwent surgical repair. In all three groups, improvements were noted in resting systolic blood pressure (BP) and upper to lower extremity BP gradients (ULG) both acutely and at follow-up. Patients who underwent stent had better acute improvement in ULG, as well as shorter hospital stays. At short and intermediate follow-up, surgical and stent patients were found to have lower ULG. Patients who underwent stent had significantly lower acute complications than both surgical and BA patients (2.9%, 16% and 10.3% respectively; p<0.001), though overall re-intervention was higher with stent vs surgical and BA pts (22.5% vs 8.2% vs 15.6%; p<0.01) with BA more likely to require unanticipated re-intervention than stent or surgery respectively (14.2% vs 8.8% vs 8.2%; p< 0.01). BA pts were more likely to encounter aortic wall injury both at short and intermediate follow-up than surgical and stent groups (p<0.01)

Conclusion:

The recommended intervention for coarctation of the aorta is likely to remain a controversial issue within Pediatric Cardiology. Stents, BA and surgical repair are all viable treatment options for children. Stent placement, while linked to higher overall re-intervention rates, is associated with significantly lower procedural complications than surgery and BA, with BA pts more likely to encounter aortic wall injury at follow-up. Parents and caregivers should therefore be presented with these findings when making a choice on mode of therapy.