All Roads Lead to Flow: Open, Hybrid, and Endovascular Repair of Aortic Coarctation in Adolescents and Adults

135 

Abstract Submission 

Matthew Thompson (1), Jonathan Putnam (2), William Frankel (1), Holliann Willekes (1), Benjamin Kramer (3), Ashley Lowry (4), Patrick Vargo (5), Patcharapong Suntharos (6), Joanna Ghobrial (1), Lars Svensson (1), Eric Roselli (1)

(1) Cleveland Clinic, Cleveland, OH, (2) Case Western Reserve University School of Medicine, Cleveland, OH, (3) Cleveland Clinic, United States, (4) Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH, (5) Cleveland Clinic, Cleveland, Ohio, (6) Cleveland Clinic Foundation, Cleveland, OH

Matthew Thompson    -  Contact Me
Cleveland Clinic

Jonathan Putnam    -  Contact Me
Case Western Reserve University School of Medicine

William Frankel    -  Contact Me
Cleveland Clinic

Holliann Willekes    -  Contact Me
Cleveland Clinic

Benjamin Kramer    -  Contact Me
Cleveland Clinic

Ashley Lowry    -  Contact Me
Cleveland Clinic, Department of Quantitative Health Sciences

Patrick Vargo    -  Contact Me
Cleveland Clinic

Patcharapong Suntharos    -  Contact Me
Cleveland Clinic Foundation

Joanna Ghobrial    -  Contact Me
Cleveland Clinic

*Lars Svensson    -  Contact Me
Cleveland Clinic

*Eric Roselli    -  Contact Me
Cleveland Clinic

Matthew Thompson    -  Contact Me
Cleveland Clinic

Objective: Optimal management of coarctation of the aorta (CoA) in adolescents and adults remains controversial. We report early and late outcomes of open surgical, hybrid, and endovascular repair, evolution of approaches over time, and the longitudinal effect of treatment on anti-hypertensive medication regimens.
Methods: Patients, age >10 years, who underwent primary CoA repair between 1999–2023 were reviewed from a prospectively maintained institutional database. Operative repair trends were evaluated. Longitudinal gradient boosting models were used to predict the probability of postoperative anti-hypertensive use over time. Reoperation and survival were evaluated by Kaplan–Meier methods; median follow-up was 6.8 years with 790 patient-years available.
Results: One-hundred ten patients (age 38+/-16 years; 62% male) underwent CoA repair. Bicuspid aortic valve was present in 48% (N=53), and 38% (N=42) had additional congenital cardiac anomalies. Most patients (90%, N=90/100) had hypertension. Operative techniques were open repair (N=42, 38% [N=25, 60% extra-anatomic bypass]), hybrid repair (N=7, 6% [N=6, 86% frozen elephant trunk]), and endovascular repair (N=61, 56%). Endovascular repair increased in frequency over the study period. Devices used included balloon-expandable stents (bare metal [N=33, 51%] and covered [N=10, 15%]), and self-expanding stent grafts (N=22, 34%). The left subclavian artery was left uncovered in 74% (N=45/60) and revascularized in 21% (N=13/60). Operative mortality was 0.9% (N=1/110), major morbidity including stroke (2.1%, N=2/96) and acute renal failure requiring dialysis (1.0%, N=1/96) were uncommon. Probability of using anti-hypertensive medications fell and stabilized, by two years postoperatively following open repair (Figure 1A), versus an increasing probability of more anti-hypertensive medications beyond two-years following endovascular repair (Figure 1B). Freedom from reintervention at 1, 5, and 10 years following open repair was 98%, 95%, and 95% and following endovascular repair was 91%, 75%, and 64% (Figure 1C). Overall survival at 1, 5, and 10 years was 98%, 98%, and 94%.
Conclusions: A tailored approach to coarctation repair in adolescents and adults with a shift toward endovascular repair when anatomically feasible has yielded excellent outcomes with respect to reintervention and survival. However, the effect on blood pressure control may indicate more durable CoA repair following open interventions.

Adult Congenital