Stent Implantations Are an Option for Small PatientsStent Implantations Are an Option for Small Patients https://pediatricsnationwide.org/wp-content/uploads/2020/09/AdobeStock_93001580-1024x670.jpg 1024 670 Mary Bates, PhD Mary Bates, PhD https://secure.gravatar.com/avatar/c6233ca2b7754ab7c4c820e14eb518c8?s=96&d=mm&r=g
- August 31, 2021
- Mary Bates, PhD
Stents that can be dilated to adult size are safe and effective for the treatment of coarctation of the aorta in young patients.
Studies have demonstrated stent implantation is more effective and safer than balloon angioplasty for the treatment of coarctation of the aorta in adult and older pediatric patients. In smaller patients, however, particularly in those weighing 20kg or less, balloon angioplasty is more commonly performed. This is partly due to the unique challenges smaller patients present, including smaller vessel sizes, the limitations of current technology and materials, and the expected growth of the patient.
At Nationwide Children’s Heart Center, the therapeutic approach to coarctation of the aorta is determined by a multidisciplinary group on a case-by-case basis. Since 2004, clinicians at Nationwide Children’s have sometimes opted for implantation of a stent that can be dilated to adult size in the future.
In a new study, researchers from Nationwide Children’s evaluated outcomes of this approach for the treatment of coarctation of the aorta in very young patients weighing less than 20kg. The researchers reviewed the cases of 39 patients over a period of 12 years who underwent stent implantation at The Heart Center.
Overall, the researchers found that stent implantation is a safe and effective option for these patients, with an acute procedural success rate of 97%. One patient had an aneurysm, which was treated with another catheterization procedure.
“We were able to double the size of the stenotic lesion and significantly decrease the pressure gradient down to a median of 0mm mercury, essentially completely eliminating the pressure gradient,” says Brian Boe, MD, a congenital interventional cardiologist at Nationwide Children’s and one of the study’s authors.
As with all interventions in congenital cardiology, the procedure is not without risks. Seven patients (18%) experienced adverse events, the most common being vascular injury.
“One of the risks of doing this procedure in small children is that you can injure the femoral artery,” says Aimee Armstrong, MD, Director of Cardiac Catheterization and Interventional Therapies at Nationwide Children’s and another of the study’s authors. “In this study, 14% of the patients had a vascular injury long-term.”
In addition, since small patients grow, the vast majority of patients had to return to the catheterization laboratory for another procedure to enlarge their stent, on average about four years after the first procedure.
Over a five-year follow-up period, about 70% of patients were without significant complications of aortic coarctation, meaning they did not have hypertension and there was no pressure difference as measured by blood pressure cuffs in clinic.
Dr. Armstrong, who is also a professor of pediatrics at The Ohio State University College of Medicine, says that although the overall results are positive, they would like to see fewer patients experiencing vascular injury.
“Our current available technology can be used for this lesion in these small patients, but it was not designed for that purpose,” she says. “The risk of vascular injury could be minimized in the future by the development of lower profile stents that can fit through a smaller catheter but still be dilated to adult size.”
Dr. Boe, who is also an assistant professor of pediatrics at The Ohio State University College of Medicine, points to clinical changes made over the study period that also decreased the risk of vascular injury.
“These changes include using ultrasound guidance to help guide vascular access and instituting protocols for the early identification and treatment of vascular injuries,” he says. “We have shown that these interventions decreased the rate of these access-related complications.
“As new stent technologies are developed, this treatment modality will become even safer for more patients and smaller patients.”
Boe BA, Armstrong AK, Janse SA, Loccoh EC, Stockmaster K, Holzer RJ, Cheatham SL, Cheatham JP, and Berman DP. Percutaneous implantation of adult sized stents for coarctation of the aorta in children </=20 kg: A 12-year experience. Circulation: Cardiovascular Interventions 2021;14:e009399. Doi: 10.1161/CIRCINTERVENTIONS.120.009399
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