Page 24 - Journal of Structural Heart Disease Volume 3, Issue 5

Case Report 150
AB
Figure 3. Patient aortography before (Panel A) and after (Panel B) stenting of the aortic arch and isthmus. Before stent implantation, there was severe stenosis of the aortic arch (arrow) and ostial stenosis of the left subclavial artery.
required repeated dilatation depending on the child’s growth [13].
In our case, patient observation revealed a rapid development of aortic arch obstruction after initial correction of common arterial trunk and manage- ment of coarctation of the aorta. Performing PTA in this particular case was impractical due to the length of the obstructed segment, as PTA is often ine ective in patients with long stenosis and kinking or patients with hypoplastic distal aortic arch. Stent implanta- tion is a more e ective management strategy for this pathology, but stenting in infants and children is not always possible due to problems associated with de- livering a stent suitable for future expansion as the patient grows. The use of stents that cannot be ex- panded to an adult size is not recommended and is only done in extreme emergencies [14, 15].
To overcome problems associated with the use of large-diameter delivery systems and balloon cathe- ters as well as stents (e.g., GenezisXD, CP stent, An- drastents, Intrastent) with the potential for further re-dilatation to the size of an adult vessel, a hybrid stenting technique was proposed. These stents are manually mounted on a balloon catheter of the cor- rect diameter and implanted without the use of long
delivery devices [12, 13]. Pediatric interventional car- diologists have recently started to use Valeo stents (Bard Peripheral Vascular, Inc., Tempe, AZ, USA) with a diameter of 6-10 mm for stenting large vessels. These stents are already mounted on the balloon catheter, have a low pro le, require the use of 6-7-F introduc- ers, and have the possibility of subsequent dilatation up to 20 mm in diameter [16]. In our case, we used a Valeo stent. In the future, we plan to monitor patient status and the gradient across the stent. As the child grows, if necessary, further balloon dilatation of the stent will be performed to achieve the required size.
For hybrid stenting of arch obstruction and aortic isthmus in our patient, we achieved access through the descending thoracic aorta. To our knowledge, this is the rst report describing this technique in the liter- ature. Positioning the patient on his or her side makes it possible to visualize the aortic arch without signi - cant axial projections of the “C-arm”, which is import- ant when performing an intervention in a standard cardiac surgical operating room. The use of lateral thoracotomy permits the avoidance of repeated ster- notomy in patients without need for other cardiac interventions. Delivery of a 6-F system during implan- tation of Valeo stents through the thoracic descend-
Journal of Structural Heart Disease, October 2017
Volume 3, Issue 5:147-151