What is the treatment for coarctation of the aorta?

Treatment of Coarctation of the Aorta

For older children (>25 kg) and adults, transcatheter treatment with covered stent placement is the first-choice treatment, while surgical resection remains the treatment of choice for neonates, infants, and young children. 1, 2

Indications for Intervention

Intervention is warranted when specific hemodynamic criteria are met:

• Hypertensive patients (>140/90 mmHg in adults) with a non-invasive arm-to-leg gradient >20 mmHg should undergo intervention, with preference for stenting when technically feasible. 1
• Hypertensive patients with >50% aortic narrowing relative to the diameter at the diaphragm level should be considered for endovascular treatment even if the invasive gradient is <20 mmHg. 1
• Normotensive patients with invasive peak-to-peak gradient >20 mmHg should be considered for endovascular treatment when technically feasible. 1

Treatment Approach by Age and Patient Size

Neonates, Infants, and Young Children (<25 kg)

• Surgical resection is the treatment of choice in this age group. 2
• Surgical techniques include end-to-end anastomosis, subclavian flap, and patch aortoplasty. 3
• Immediate surgical mortality is approximately 2%, with excellent long-term survival. 3

Older Children (>25 kg) and Adults

• Transcatheter treatment with covered stent placement is the first-choice treatment. 1, 2
• Balloon angioplasty without stenting may be considered if stent placement is not feasible and surgical intervention is not an option, though it carries higher recurrence rates and risk of aneurysm formation. 1
• The choice between surgical and transcatheter approaches depends on patient anatomy, size, age, and the experience of the medical-surgical team. 4, 3

Pre-Intervention Diagnostic Work-Up

Before any intervention, complete hemodynamic and anatomic assessment is mandatory:

• Obtain blood pressure measurements in both arms and one lower extremity to document gradients. 1, 5
• CMR or cardiac CT should be used to visualize the entire thoracic aorta, define the coarctation anatomy, assess for arch hypoplasia, identify collateral vessels, and detect aneurysms. 1, 5
• Invasive catheterization with manometry remains the gold standard for confirming hemodynamic significance (peak-to-peak gradient >20 mmHg) before intervention. 1, 5
• Transthoracic echocardiography is the primary imaging modality for initial suspected coarctation. 2

Lifelong Surveillance Requirements

All coarctation patients require lifelong follow-up regardless of treatment success, as they remain at risk for complications even after successful repair. 1, 5

Imaging Surveillance

• CMR or cardiac CT every 3-5 years to monitor for re-coarctation, aneurysms, pseudoaneurysms, and dissection. 1, 5
• Regular imaging is essential as both surgical and transcatheter interventions can produce damage to the aorta with subsequent development of aneurysms. 5

Blood Pressure Monitoring

• 24-hour ambulatory blood pressure monitoring or exercise testing better detects hypertension than office measurements alone. 1, 5
• Hypertension should be treated according to standard hypertension guidelines. 1, 5
• Hypertension remains common even after successful treatment and is more prevalent when initial repair is performed in adulthood. 5

Associated Conditions Requiring Monitoring

• Surveillance for bicuspid aortic valve dysfunction and ascending aortic dilation is mandatory in patients with coarctation. 1
• Screening for intracranial aneurysms by MRA or CTA may be reasonable, though routine screening in asymptomatic patients is not currently evidence-based. 1, 5

Common Pitfalls and Complications

Recoarctation

• Recoarctation occurs in approximately 8% of patients, affecting both surgical and percutaneous approaches. 3
• Endovascular treatment with stenting is the first-choice treatment for re-coarctation in adults when technically feasible. 5

Persistent Hypertension

• Hypertension is a critical long-term complication that increases risk of aortic dissection, particularly in untreated cases. 5
• Delay in treatment has a direct impact on late morbidity and mortality, with patients diagnosed later in life having higher rates of persistent hypertension. 3

Aortic Dissection Risk

• Aortic dissection can occur both proximal and distal to the coarctation site, typically in the third decade of life or later in untreated cases. 5
• Pregnancy represents a period of increased risk for dissection. 5