Tough Calls: Case 3

Aortic Atresia and Hypertension

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 

33 year old gentlemen; mechanical AVR for bicuspid disease 8 years prior to diagnoses of CoA – atresia. Severe Residual Hypertension. 

Expert Approaches

Hover over an experts image to view their approach.

•Access: Radial artery (monitoring/angiography), femoral artery

•Simultaneous angios above/below coarctation (likely 3DRA)

•If possible to get through with wire, then start with that. If not, consider straight Chiba needle versus RF wire (most likely from femoral approach, but can also perform from radial if anatomy more amenable)

•Snare the wire and externalize from radial through femoral artery

•Place sheath from femoral artery retrograde through the CoA (may require balloon dilation to assist sheath through (simultaneous deflation while advancing the sheath)

•CP covered stent implantation and dilation (may require ultra-high pressure balloons to remove residual stenosis/gradient

Dr. Matthew Crystal
MD, FACC, FSCAI
 
New York-Presbyterian & Morgan Stanley Children's Hospital
Assistant Professor of Pediatrics, Columbia University Medical Centre

•Use CT and Cath for measurements 

•Access: 6f RRA & 8f RFA + proglide

•Attempt to cross from below with straight 0.035 wire and 6f catheter (aim to deliver to arch or right subclavian artery so can exchange for Amplatzer extrastiff wire)

•If can't cross from below, try from above (exchange length Terumo wire or coronary wire) then snare below and externalize to create a rail. If externalize 035 wire, use a 4-5Fr glidecath or pigtail from femoral artery to cross the coarctation from below then deliver Amplatzer extrastiff wire to ascending aorta 

•Cross coarctation with large sheath that will accommodate appropriate size covered stend (12-14Fr)

•No predilation unless sheath won't cross 

•45/55mm 8zig CP covered stent mounted on BIB balloon

Dr. William Wilson
MBBS, PhD, FACC
 
Consultant Cardiologist at Royal Melbourne Hospital

•FA, bilateral radial arteries access

•Angio from above and below

•Use stiff end of glide wire/TS needle to puncture atretic segment

•Covered stent

•Make sure the LSC A is not occluded, if it is, perforate the ePTFE and balloon/stent the LSCA

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP
 
William B. Strong Chair & Professor & Section Chief Division of Pediatric Cardiology
Children's Hospital of Georgia, Augusta University
  • Aortic coarctation with atresia (interrupted aortic arch)

  • Right radial 6Fr, R CFA 6Fr

  • Start with pigtails in aortic arch and prox descending aorta for good

  • Angio of occlusion (biplane helpful to profile occlusion and target crossing)

  • Use RF wire and MP catheter to perforate the occlusion to cross

  • Initial dilation with coronary balloon (4.0x20) over 0.014” RF wire

  • Advance catheter over RF wire to exchange for 0.035” stiff wire

  • Serial balloon dilation followed by placement of CP covered stent

Dr.John Carroll
MD, FACC, MSCAI
 
Professor of Medicine, University of Colorado Denver
Director of Interventional Cardiology

I would access left brachial artery, as well as the femoral artery and try to cross with a 0.035” Terumo wire from above. You need to recanalize. Alternatively, use the stiff end of a wire biplane until you cross the atretic segment, then snare wire from DAO, then cross with 12fr sheath from femoral artery, then place a covered CP stent(14mmx34mm), with less than half of it covering the subclavian.

Dr. Ziyad Hijazi
Professor of Pediatrics & Medicine, Weill Cornell Medicine
Chair, Department of Pediatrics and Director, Sidra Cardiac Program

 

•Vascular surgery for right carotid-subclavian bypass graft. 

•Move patient to cath lab under same anesthesia

•Right radial artery access and femoral artery access.  Puncture atretic membrane with RFA wire  (from below) or back end of coronary wire (from above).  Cross with microcatheter and coronary wire.  Snare wire and externalize.

•Upsize wire.  Dilate atretic tract to accommodate 12 Fr shuttle sheath

•Place long CP covered stent on 12 mm BiB; bring back in 3-6 months to complete stent dilation

MD, FSCAI
 
Dr. Nathan Taggart

Pediatric Interventional Cardiologist 
Assistant Professor of Pediatrics
Mayo Clinic