Primary Stent Implantation for Coarctation in Neonates: Going beyond Emergency Palliation to a Definitive Coarctation Repair?

Objective: In selected neonates, primary stent implantation may be indicated for coarctation of the aorta. We describe our experience with five consecutive patients.

Methods: Five neonates in decompensated heart failure (age range: 6–11 days, weight at procedure: 2,100–4,200 g) underwent stent implantation as primary therapy for coarctation of the aorta. Indications for primary stenting were: cardiac shock due to prostaglandin resistant duct occlusion (n = 2), associated severe aortic valve stenosis (n = 1), distal arch hypoplasia and associated large ventricular septal defect (n = 2) requiring mayor surgery. Minimal isthmus diameter was 0.8 and 1.5 mm. Vascular access was achieved via femoral artery (4 F sheath) in one patient and via axillary artery (5F Gliedesheath Terumo) in the reminder. Pro-Kinetic Energy coronary stents (Biotronik, 3.5 and 5 mm, length: 13 mm) were implanted in 2 patients and Eq. 418 vascular stents (Cook, 5 mm, length: 12 and 20 mm) in 3 patients. In one patient the lesion was predilated with a 2.5-mm coronary balloon. In one patient the aortic valve was dilated during the same procedure with a 7-mm balloon.

Results: All procedures were acutely successful with relief of heart failure, and without procedural dissection, aneurysms, serious complications or death. Femoral arterial stenosis occurred in the patient with femoral arterial access and one periprocedural stroke resolved without residue. Four patients showed no postprocedural gradient; 1 patient had a residual gradient of 10 mm Hg with anatomic narrowing. 3 stents have been removed 6 to 129 days (median = 111 days) after placement (2 coronary stents and 1 Formula stent). The hypoplastic arch grew adequately in the two patients where the stent remained longer in place and patch enlargement could be avoided during follow up surgery. The patients with in-situ remaining stents show good results at a median follow-up of 10 months. One expandable Formula stent has been redilated with an 8 mm Balloon 234 days after placement.

Conclusion: Primary stenting of neonatal coarctation is a good alternative to surgery for babies with unstable hemodynamics and concomitant complex congenital heart disease. Access is best via the right axillary artery to avoid vascular injury. As the 5 mm formula stent is delivered through a small 5 F Terumo sheath, can be redilated to 12 mm and is breakable beyond that diameter, neonatal stenting of aortic coarctation is valid for definitive treatment.