Discussion
The first surgical repair of CoA was applied in 1944 [5]. Since then, surgical methods improved which resulted in extended survival of patients, and therefore, a greater number of patients with CoA reached adulthood. According to recent studies, the survival of patients operated at a median age of 16 years is 91% at 10 years, 84% at 20 years and 72% at 30 years after operation [6]. Although early diagnosis and treatment are paramount for improving outcomes, in cases with delayed diagnosis, repair of the aortic coarctation is still recommended at an older age, which results in improved blood pressure regulation and lower risk of cardiovascular events and improves survival. In more than 70% of the patients, death during the late period after treatment is the result of a cardiovascular complication [6].
Transcatheter treatment for aortic coarctation has recently become the treatment of choice due to its various technical advantages, including feasibility, relative safety, shorter hospitalization and fewer surgical complications. Due to the increased fibrosity and rigidity of the aorta in older age, stent placement is preferred instead of balloon angioplasty, an approach which has been shown to result in an almost complete relief of the gradient in >95% of the patients [6].
Re-coarctation after surgery is observed in 44% of neonates and in 11% of older children, whereas the risk is lower but still relevant in adulthood (less than 9%) [4,6]. About 9% of surgically-treated patients can develop aneurysms or pseudo-aneurysms, while those treated with balloon dilatation carry a much higher risk (20%). Additionally, individuals with coexisting bicuspid aortic valves are at an increased risk of developing aortic root dilatation [4].
For the treatment of recurrent aortic coarctation, primary balloon angioplasty with or without stent implantation has become the first-choice treatment. In the long-term, percutaneous balloon angioplasty for re-coarctation is accepted to be reliable; however, further surgical intervention or transcatheter intervention may be needed in patients with transverse arch hypoplasia, and the use of stenting is demonstrated to be effective in treating patients with hypoplastic isthmus, arch or tubular coarctation [6]. The operational technique should be determined with respect to the characteristics of each patient. While most patients with re-coarctation will usually be suitable candidates for transcatheter treatment, complex anatomy and/or cardiac comorbidities may favor a surgical approach or could warrant hybrid techniques [7].
In this case of a late re-coarctation, we preferred to apply a hybrid technique. Debranching the brachiocephalic and left common carotid arteries with upper mini median sternotomy was the first step of our treatment process. On the following day, the patient underwent a successful stent placement. The patient was discharged on the postoperative third day, without any complications.