Mid Term Results of Endovascular Treatment of Pseudoaneurysms After Remote Surgery for Aortic Coarctation: A Review of the Literature
Dan Badia, DO, George Koullias, M.D., Apostolos Tassiopoulos, M.D..
Stony Brook University Hospital and Southampton Hospital, Stony Brook, NY, USA.
OBJECTIVES:Surgery remains the standard of care for congenital Aortic coarctation. Four surgical techniques have been applied. In the late 80’s, several reports showed high (15-38%) Incidence of late pseudo aneurysm mainly with patch aortoplasty, but also with the other techniques. Late pseudoaneurysms have a non size related, high rupture risk that is 100% in 15 years and is responsible for 7-10% of deaths of the long-term survivors after surgical repair. Their proximity to the bronchial tree can lead to Aortobronchial fistula and hemoptysis. Surgical repair of these lesions is associated with considerable morbidity and mortality including pulmonary complications ,paraplegia, bleeding, and recurrent nerve injury. Endovascular stent graft repair is a very attractive alternative, with unknown mid and long term durability data. METHODS:Systematic search of MEDLINE in English , using the key phrase: pseudoaneurysm coarctation, endovascular repair coarctation, up to 10/2016 ** 9 case series (>/5 pts), 3 single center retrospective analysis, 6 small case series (</4 pts), 14 case reports (1 pt each) Comparisons were made using attributes including male and female gender, 30 day mortality, paraplegia, stroke, and endoleaks. Additionally a separate analysis was carried out on the three largest and most recent case series regarding this data. This was undertaken to understand the long term viability and reintervention necessity of this repair. These were chosen due to their superior reporting on re-intervention and endoleaks. RESULTS: Pseudoaneurysms are discovered approximately 25+years after initial procedure. One out of three patients are symptomatic. One third of symptomatic patients will have hemoptysis. Overall 15% of patients need emergent treatment. Technical success of endovascular treatment, morbidity, and endoleak incidence are acceptable, mortality is 3% in all comers. In addition, combining the most recent studies with the longest follow up (mean45 months), the average re-intervention rate was 21.9%, with continued technical success in almost all patients. CONCLUSIONS:The incidence of late pseudoaneurysms after coarctation repair is expected to increase. A staged endovascular repair of these lesions with preoperative left subclavian artery bypass/transposition and use of customized flexible endografts, fitting individual anatomies, is a very safe alternative to open repair with excellent mid term results. Life long surveillance is required to determine long term durability and incidence of secondary procedures.
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