Current Cardiology Reports

, 21:99 | Cite as

The Challenges of Redo Aortic Coarctation Repair in Adults

  • Jonathan D. Price
  • Damien J. LaParEmail author
Structural Heart Disease (RJ Siegel and NC Wunderlich, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Structural Heart Disease


Purpose of Review

Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts.

Recent Findings

Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention.


Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.


Coarctation Aorta Pediatric Congenital Long-term Outcomes 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Warnes CA, et al. ACC/AHA 2008 Guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Developed in collaboration with the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(23):e143–263. This reference provides important ACC/AHA consensus guidelines to direct management for adult congenital heart diesease. CrossRefGoogle Scholar
  2. 2.
    Ringel RE, Gauvreau K, Moses H, Jenkins KJ. Coarctation of the aorta stent trial (COAST): study design and rationale. Am Heart J. 2012;164(1):7–13.CrossRefGoogle Scholar
  3. 3.
    Baumgartner H, Bonhoeffer P, de Groot NM, de Haan F, Deanfield JE, Galie N, et al. ESC guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J. 2010;31(23):2915–57.CrossRefGoogle Scholar
  4. 4.
    Doshi AR, Chikkabyrappa S. Coarctation of aorta in children. Cureus. 2018;10(12):e3690.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Campbell M. Natural history of coarctation of the aorta. Br Heart J. 1970;32(5):633–40.CrossRefGoogle Scholar
  6. 6.
    Burch PT, Cowley CG, Holubkov R, Null D, Lambert LM, Kouretas PC, et al. Coarctation repair in neonates and young infants: is small size or low weight still a risk factor? J Thorac Cardiovasc Surg. 2009;138(3):547–52.CrossRefGoogle Scholar
  7. 7.
    • Mery CM, et al. Contemporary results of aortic coarctation repair through left thoracotomy. Ann Thorac Surg. 2015;100(3):1039–46. An important reference highlighting recent surgical results for the most common approach to surgical repair of aortic coarctation—the left thoracotomy. CrossRefGoogle Scholar
  8. 8.
    Karamlou T, Bernasconi A, Jaeggi E, Alhabshan F, Williams WG, van Arsdell GS, et al. Factors associated with arch reintervention and growth of the aortic arch after coarctation repair in neonates weighing less than 2.5 kg. J Thorac Cardiovasc Surg. 2009;137(5):1163–7.CrossRefGoogle Scholar
  9. 9.
    Feltes TF, Bacha E, Beekman RH 3rd, Cheatham JP, Feinstein JA, Gomes AS, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation. 2011;123(22):2607–52.CrossRefGoogle Scholar
  10. 10.
    Torok RD, et al. Coarctation of the aorta: management from infancy to adulthood. World J Cardiol. 2015;7(11):765–75.CrossRefGoogle Scholar
  11. 11.
    Cowley CG, Orsmond GS, Feola P, McQuillan L, Shaddy RE. Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood. Circulation. 2005;111(25):3453–6.CrossRefGoogle Scholar
  12. 12.
    McCrindle BW, Jones TK, Morrow WR, Hagler DJ, Lloyd TR, Nouri S, et al. Acute results of balloon angioplasty of native coarctation versus recurrent aortic obstruction are equivalent. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators. J Am Coll Cardiol. 1996;28(7):1810–7.CrossRefGoogle Scholar
  13. 13.
    Shaddy RE, Boucek MM, Sturtevant JE, Ruttenberg HD, Jaffe RB, Tani LY, et al. Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation. 1993;87(3):793–9.CrossRefGoogle Scholar
  14. 14.
    Walhout RJ, Suttorp MJ, Mackaij GJ, Ernst JMPG, Plokker HWM. Long-term outcome after balloon angioplasty of coarctation of the aorta in adolescents and adults: is aneurysm formation an issue? Catheter Cardiovasc Interv. 2009;73(4):549–56.CrossRefGoogle Scholar
  15. 15.
    Kaushal S, Backer CL, Patel JN, Patel SK, Walker BL, Weigel TJ, et al. Coarctation of the aorta: midterm outcomes of resection with extended end-to-end anastomosis. Ann Thorac Surg. 2009;88(6):1932–8.CrossRefGoogle Scholar
  16. 16.
    Hesslein PS, McNamara DG, Morriss MJ, Hallman GL, Cooley DA. Comparison of resection versus patch aortoplasty for repair of coarctation in infants and children. Circulation. 1981;64(1):164–8.CrossRefGoogle Scholar
  17. 17.
    Kappetein AP, Zwinderman AH, Bogers AJ, Rohmer J, Huysmans HA. More than thirty-five years of coarctation repair. An unexpected high relapse rate. J Thorac Cardiovasc Surg. 1994;107(1):87–95.PubMedGoogle Scholar
  18. 18.
    Beckmann E, Jassar AS. Coarctation repair-redo challenges in the adults: what to do? J Vis Surg. 2018;4:76.CrossRefGoogle Scholar
  19. 19.
    Adjagba PM, Hanna B, Miró J, Dancea A, Poirier N, Vobecky S, et al. Percutaneous angioplasty used to manage native and recurrent coarctation of the aorta in infants younger than 1 year: immediate and midterm results. Pediatr Cardiol. 2014;35(7):1155–61.CrossRefGoogle Scholar
  20. 20.
    Rao PS, Galal O, Smith PA, Wilson AD. Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol. 1996;27(2):462–70.CrossRefGoogle Scholar
  21. 21.
    Fawzy ME, Fathala A, Osman A, Badr A, Mostafa MA, Mohamed G, et al. Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults. Am Heart J. 2008;156(5):910–7.CrossRefGoogle Scholar
  22. 22.
    Fletcher SE, Nihill MR, Grifka RG, O'Laughlin MP, Mullins CE. Balloon angioplasty of native coarctation of the aorta: midterm follow-up and prognostic factors. J Am Coll Cardiol. 1995;25(3):730–4.CrossRefGoogle Scholar
  23. 23.
    Rao PS, Thapar MK, Kutayli F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Coll Cardiol. 1989;13(1):109–15.CrossRefGoogle Scholar
  24. 24.
    Pourmoghadam KK, Velamoor G, Kneebone JM, Patterson K, Jones TK, Lupinetti FM. Changes in protein distribution of the aortic wall following balloon aortoplasty for coarctation. Am J Cardiol. 2002;89(1):91–3.CrossRefGoogle Scholar
  25. 25.
    Knyshov GV, Sitar LL, Glagola MD, Atamanyuk MY. Aortic aneurysms at the site of the repair of coarctation of the aorta: a review of 48 patients. Ann Thorac Surg. 1996;61(3):935–9.CrossRefGoogle Scholar
  26. 26.
    Parikh SR, Hurwitz RA, Hubbard JE, Brown JW, King H, Girod DA. Preoperative and postoperative “aneurysm” associated with coarctation of the aorta. J Am Coll Cardiol. 1991;17(6):1367–72.CrossRefGoogle Scholar
  27. 27.
    von Kodolitsch Y, Aydin MA, Koschyk DH, Loose R, Schalwat I, Karck M, et al. Predictors of aneurysmal formation after surgical correction of aortic coarctation. J Am Coll Cardiol. 2002;39(4):617–24.CrossRefGoogle Scholar
  28. 28.
    Attenhofer Jost CH, et al. Spectrum of reoperations after repair of aortic coarctation: importance of an individualized approach because of coexistent cardiovascular disease. Mayo Clin Proc. 2002;77(7):646–53.CrossRefGoogle Scholar
  29. 29.
    Stout KK, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2019;73(12):1494–563.CrossRefGoogle Scholar
  30. 30.
    Mendelsohn AM, Crowley DC, Lindauer A, Beekman RH III. Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta. J Am Coll Cardiol. 1992;20(2):381–5.CrossRefGoogle Scholar
  31. 31.
    Oliver JM, Gallego P, Gonzalez A, Aroca A, Bret M, Mesa JM. Risk factors for aortic complications in adults with coarctation of the aorta. J Am Coll Cardiol. 2004;44(8):1641–7.CrossRefGoogle Scholar
  32. 32.
    Parks WJ, Ngo TD, Plauth WH Jr, Bank ER, Sheppard SK, Pettigrew RI, et al. Incidence of aneurysm formation after Dacron patch aortoplasty repair for coarctation of the aorta: long-term results and assessment utilizing magnetic resonance angiography with three-dimensional surface rendering. J Am Coll Cardiol. 1995;26(1):266–71.CrossRefGoogle Scholar
  33. 33.
    •• Hiratzka LF, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Catheter Cardiovasc Interv. 2010;76(2):E43–86. Important reference with consensus guidelines for the diagnosis, management, and surgical treatment of thoracic aortic disease, including the roles for trans-catheter approaches to thoracic aortic disease. CrossRefGoogle Scholar
  34. 34.
    Erbel R, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41):2873–926.CrossRefGoogle Scholar
  35. 35.
    Kron IL, Flanagan TL, Rheuban KS, Carpenter MA, Gutgesell HP Jr, Blackbourne LH, et al. Incidence and risk of reintervention after coarctation repair. Ann Thorac Surg. 1990;49(6):920–5 discussion 925-6.CrossRefGoogle Scholar
  36. 36.
    Ralph-Edwards AC, Williams WG, Coles JC, Rebeyka IM, Trusler GA, Freedom RM. Reoperation for recurrent aortic coarctation. Ann Thorac Surg. 1995;60(5):1303–7.CrossRefGoogle Scholar
  37. 37.
    Forbes TJ, Garekar S, Amin Z, Zahn EM, Nykanen D, Moore P, et al. Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: a multi-institutional study. Catheter Cardiovasc Interv. 2007;70(2):276–85.CrossRefGoogle Scholar
  38. 38.
    Forbes TJ, Gowda ST. Intravascular stent therapy for coarctation of the aorta. Methodist Debakey Cardiovasc J. 2014;10(2):82–7.CrossRefGoogle Scholar
  39. 39.
    Forbes TJ, Kim DW, du W, Turner DR, Holzer R, Amin Z, et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: an observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol. 2011;58(25):2664–74.CrossRefGoogle Scholar
  40. 40.
    Forbes TJ, Moore P, Pedra CAC, Zahn EM, Nykanen D, Amin Z, et al. Intermediate follow-up following intravascular stenting for treatment of coarctation of the aorta. Catheter Cardiovasc Interv. 2007;70(4):569–77.CrossRefGoogle Scholar
  41. 41.
    Saxena A. Recurrent coarctation: interventional techniques and results. World J Pediatr Congenit Heart Surg. 2015;6(2):257–65.CrossRefGoogle Scholar
  42. 42.
    Arfi AM, Galal MO, Kouatli A, Baho H, Abozeid H, al Ata J. Stent angioplasty for critical native aortic coarctation in three infants: up to 15-year follow-up without surgical intervention and review of the literature. Pediatr Cardiol. 2018;39(8):1501–13.CrossRefGoogle Scholar
  43. 43.
    Pan M, et al., Percutaneous reintervention in patients with aortic coarctation stenting at an early age. EuroIntervention, 2019Google Scholar
  44. 44.
    Cools B, Brown S, Gewillig M. Adverse outcome of coarctation stenting in patients with Turner syndrome. Catheter Cardiovasc Interv. 2018;92(3):E212–3.CrossRefGoogle Scholar
  45. 45.
    Firoozi A, Mohebbi B, Noohi F, Bassiri H, Mohebbi A, Abdi S, et al. Self-expanding versus balloon-expandable stents in patients with isthmic coarctation of the aorta. Am J Cardiol. 2018;122(6):1062–7.CrossRefGoogle Scholar
  46. 46.
    Wright GE, Nowak CA, Goldberg CS, Ohye RG, Bove EL, Rocchini AP. Extended resection and end-to-end anastomosis for aortic coarctation in infants: results of a tailored surgical approach. Ann Thorac Surg. 2005;80(4):1453–9.CrossRefGoogle Scholar
  47. 47.
    Kottayil BP, Bayya PR, Baquero L, Sen AC, Kumar RK. Modified technique for uncommon coarctation of the aorta with arch hypoplasia. Ann Pediatr Cardiol. 2018;11(3):275–7.CrossRefGoogle Scholar
  48. 48.
    Yousif A, Kloppenburg G, Morshuis WJ, Heijmen R. Repair of adult aortic coarctation by resection and interposition grafting. Interact Cardiovasc Thorac Surg. 2016;23(4):526–30.CrossRefGoogle Scholar
  49. 49.
    Pandey R, Jackson M, Ajab S, Gladman G, Pozzi M. Subclavian flap repair: review of 399 patients at median follow-up of fourteen years. Ann Thorac Surg. 2006;81(4):1420–8.CrossRefGoogle Scholar
  50. 50.
    Bambul Heck P, Pabst von Ohain J, Kaemmerer H, Ewert P, Hager A. Survival and cardiovascular events after coarctation-repair in long-term follow-up (COAFU): predictive value of clinical variables. Int J Cardiol. 2017;228:347–51.CrossRefGoogle Scholar
  51. 51.
    Mauney MC, Tribble CG, Cope JT, Tribble RW, Luctong A, Spotnitz WD, et al. Is clamp and sew still viable for thoracic aortic resection? Ann Surg. 1996;223(5):534–40 discussion 540-3.CrossRefGoogle Scholar
  52. 52.
    Tefera G, Acher CW, Wynn MM. Clamp and sew techniques in thoracoabdominal aortic surgery using naloxone and CSF drainage. Semin Vasc Surg. 2000;13(4):325–30.PubMedGoogle Scholar
  53. 53.
    Acher C. It is not just assisted circulation, hypothermic arrest, or clamp and sew. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S136–41 discussion S142-S146.CrossRefGoogle Scholar
  54. 54.
    Fiore AC, Ruzmetov M, Johnson RG, Rodefeld MD, Rieger K, Turrentine MW, et al. Selective use of left heart bypass for aortic coarctation. Ann Thorac Surg. 2010;89(3):851–6 discussion 856-7.CrossRefGoogle Scholar
  55. 55.
    Grinda JM, Macé L, Dervanian P, Folliguet TA, Neveux JY. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg. 1995;60(5):1299–302.CrossRefGoogle Scholar
  56. 56.
    Almeida de Oliveira S, Lisboa LAF, Dallan LAO, Abreu F° CAC, Rochitte CE, de Souza JM. Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results. Ann Thorac Surg. 2003;76(6):1962–6.CrossRefGoogle Scholar
  57. 57.
    Heinemann MK, Ziemer G, Wahlers T, Köhler A, Borst HG. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur J Cardiothorac Surg. 1997;11(1):169–75.CrossRefGoogle Scholar
  58. 58.
    Fruh S, et al. Comparison of surgical and interventional therapy of native and recurrent aortic coarctation regarding different age groups during childhood. Eur J Cardiothorac Surg. 2011;39(6):898–904.CrossRefGoogle Scholar
  59. 59.
    Zoghbi J, Serraf A, Mohammadi S, Belli E, Lacour Gayet F, Aupecle B, et al. Is surgical intervention still indicated in recurrent aortic arch obstruction? J Thorac Cardiovasc Surg. 2004;127(1):203–12.CrossRefGoogle Scholar
  60. 60.
    Hobbs RD, Ullery BW, Mentzer AR, Cheung AT. Protocol for prevention of spinal cord ischemia after thoracoabdominal aortic surgery. Vascular. 2016;24(4):430–4.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkUSA
  2. 2.Columbia University Vagelos College of Physicians and SurgeonsNew YorkUSA

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