Catheterization and Cardiovascular Diagnosis 39:43 (1996)
Editorial Comment
Stenting Coarctation of the
Aorta: Promising Concept But
Primitive Technology
Carlos E. Ruiz, MD, PhD, FSCAI, and
He Ping Zhang, MD
Lorna Linda University Children’s Hospital
and Medical Center,
Lorna Linda, California
The article by Bulbul et al. in this issue of the journal reports
their experience of stenting coarctation of the aorta with excellent
immediate and short-term follow-up results [11. Their study dem-
onstrates the effectiveness of the stent placement in relieving a
stenotic area of the aorta and subsequently reducing the systolic
peak-to-peak pressure gradient with a high success rate and with
no immediate complications related to stent placement. Clinical
improvement was observed in all patients who had a successful
outcome. They also showed that redilation of the stent in one case
at later follow-up was effective and safe.
Although the experience of using a stent to treat coarctation of
the aorta is limited, the unique properties of stents make this
procedure very promising, provided these devices are appropri-
ately designed for the type of pathology most frequently encoun-
tered among this young cohort of patients. Stents make sense
because they support the vessel wall thereby minimizing recoil of
the artery, for as long as they have the required hoop strength. This
property may in itself overcome the reported high recoarctation
rates (14 to 35%) encountered with balloon dilatation alone [2].
Extrapolating the experience gained from stenting other small and
large caliber arteries, we expect the rate of recoarctation of the
aorta after stent placement will be significantly lower, not only on
the basis of preventing recoil but also by minimizing the prolifer-
ative vascular response to the trauma of balloon dilatation. Fur-
thermore, stent placement may improve the endovascular surface
appearance, thereby reducing the possibility of severe complica-
tions such as acute or subacute dissection. Findings from intra-
vascular ultrasound and angiography following balloon angioplasty
of the aorta tend to support this conjecture [3]. In addition, stents,
by providing the uniform circumferential support, may reinforce
weakened areas within the lumen of the aorta that may account for
the late aneurysm formation which has been reported to be asso-
ciated with balloon dilatation [2], as well as post surgical repair [4].
Given the present available stent technology, what age, or per-
haps more appropriately, what minimal diameter of the aorta
should be considered “safe” to entertain placement of stents as an
alternative mode of therapy for coarctation of the aorta? In the
study by Bulbul et al., the mean age of their patients was 20 years
with the youngest age of 13 years [l]. In contrast, in the work by
de Lezo et al., 9 out of 10 patients undergoing stent placement
were under 12 years of age including 5 who were under 27 months
[ 5 ] . We must keep in mind that small children have not reached
0 1996 Wiley-Liss, Inc.
their full somatic and vascular development, and there is signifi-
cant risk for serious arterial damage that may be caused by the bulk
of the currently available delivery systems used to deploy those
stents. Thus only a small percentage of patients born with coarc-
tation of the aorta could safely benefit, at the present time, from
this innovative approach. Although stents have been reexpanded at
a later time, we do not know the extent of those limits and, hence,
extreme caution should be exercised when considering this exper-
imental therapy until supportive long-term follow-up data is avail-
able. This is especially true for infants and small children.
Nevertheless, the concept of using stents to treat coarctation of
the aorta seems sensible and logical. It is an idea whose time has
come. The engineering knowledge to conform smaller deployment
devices for larger expansion rates of metallic stents is available, but
the question still remains whether metallic stents are the right choice
of stents for this pediatric population. From previous animal data,
the use of polymeric biodegradable stents as performed in coronary
arteries may have some potential advantages over metallic stents
[6]. Their biodegradable capability is an extremely appealing con-
cept. This property allows polymer materials to mix with new
collagen and muscle fibers to reinforce the aortic wall after dila-
tation to assure lumen integrity. Therefore, in cases of restenosis
or arrested development of the stented area, there would be more
room for further non-surgical intervention. Even if surgery were
needed, it would probably be safer and easier than if a metal
prosthesis were present. However, such stent material should be a
polymer that does not provoke a severe local or systemic inflam-
matory process, which could cause further pathology. This pioneer
work is in its infancy. But with the close collaboration of industry,
it may in the very near future be the preferred mode of therapy.
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