Discussion
The first surgical repair of CoA was applied in 1944 [5]. Since
then, surgical methods improved which resulted in extended survival of
patients, and therefore, a greater number of patients with CoA reached
adulthood. According to recent studies, the survival of patients
operated at a median age of 16 years is 91% at 10 years, 84% at 20
years and 72% at 30 years after operation [6]. Although early
diagnosis and treatment are paramount for improving outcomes, in cases
with delayed diagnosis, repair of the aortic coarctation is still
recommended at an older age, which results in improved blood pressure
regulation and lower risk of cardiovascular events and improves
survival. In more than 70% of the patients, death during the late
period after treatment is the result of a cardiovascular complication
[6].
Transcatheter treatment for aortic coarctation has recently become the
treatment of choice due to its various technical advantages, including
feasibility, relative safety, shorter hospitalization and fewer surgical
complications. Due to the increased fibrosity and rigidity of the aorta
in older age, stent placement is preferred instead of balloon
angioplasty, an approach which has been shown to result in an almost
complete relief of the gradient in >95% of the patients
[6].
Re-coarctation after surgery is observed in 44% of neonates and in 11%
of older children, whereas the risk is lower but still relevant in
adulthood (less than 9%) [4,6]. About 9% of surgically-treated
patients can develop aneurysms or pseudo-aneurysms, while those treated
with balloon dilatation carry a much higher risk (20%). Additionally,
individuals with coexisting bicuspid aortic valves are at an increased
risk of developing aortic root dilatation [4].
For the treatment of recurrent aortic coarctation, primary balloon
angioplasty with or without stent implantation has become the
first-choice treatment. In the long-term, percutaneous balloon
angioplasty for re-coarctation is accepted to be reliable; however,
further surgical intervention or transcatheter intervention may be
needed in patients with transverse arch hypoplasia, and the use of
stenting is demonstrated to be effective in treating patients with
hypoplastic isthmus, arch or tubular coarctation [6]. The
operational technique should be determined with respect to the
characteristics of each patient. While most patients with re-coarctation
will usually be suitable candidates for transcatheter treatment, complex
anatomy and/or cardiac comorbidities may favor a surgical approach or
could warrant hybrid techniques [7].
In this case of a late re-coarctation, we preferred to apply a hybrid
technique. Debranching the brachiocephalic and left common carotid
arteries with upper mini median sternotomy was the first step of our
treatment process. On the following day, the patient underwent a
successful stent placement. The patient was discharged on the
postoperative third day, without any complications.