Eskandari, Mark K.

Objective: To evaluate outcomes of endovascular treatment of aortic coarctation in the adult, either newly diagnosed or due to recurrent coarctation and pseudoaneurysm formation Methods: Clinical data and imaging studies of 93 patients treated at nine institutions from 1999-2015 were reviewed. Primary end-points were morbidity and mortality. Secondary end-points were stent patency and need for re-intervention Results: There were 54 male and 39 female patients with a mean age of 44±17 years, including 32 with de novo coarctation (mean 48±16 years) and 61 with prior open repair during childhood, who required endovascular re-intervention (mean: 30±17 years after initial repair). Indications for treatment were: resistant hypertension (32%), left ventricular hypertrophy (23%) and claudication (20%). Imaging studies included: computed tomography angiography (CTA) (42%), CTA and magnetic resonance angiography (MRA) (37%), MRA (13%), angiography (5%) and ultrasound (2%). Endovascular treatment was performed using stent grafts (55%), balloon expandable bare metal in (28%) or covered stents (15%) and primary angioplasty alone (1%). Mean lesion length and diameter were 64±50mm and 20±7mm, respectively. Mean systolic pressure gradient decreased from 24±18mmHg to 5±8mmHg after treatment, (p<0.001). Four patients had intraprocedural complications including: rupture in two, type 1A endoleak and access hemorrhage in one each. Perioperative complications occurred in six: aortic dissection in three, thrombus migration into renal artery, spinal headache requiring blood patch and lung hemorrhage in one patient each. Two patients died within 30-days from hemorrhage and cardiopulmonary arrest. After a mean follow up time of 7±21 years, nearly all patients (98%) had symptom improvement and all stents were patent. Re-intervention was needed in 11%. 2 patients died from coarctation related causes including rupture of an infected graft and visceral ischemia Conclusions: In this multi-center study, endovascular repair was a safe and effective treatment for de novo coarctation and post-surgical complications of coarctation repair in adults. Rate of procedural complications and re-interventions were low with high procedural and long-term clinical success

BackgroundSystematic evaluation of complex flow in the true lumen and false lumen (TL, FL) is needed to better understand which patients with chronic descending aortic dissection (DAD) are predisposed to complications.PurposeTo develop quantitative hemodynamic maps from 4D flow MRI for evaluating TL and FL flow characteristics.Study TypeRetrospective.PopulationIn all, 20 DAD patients (age = 60 ± 11 years; 12 male) (six medically managed type B AD [TBAD], 14 repaired type A AD [rTAAD] now with ascending aortic graft [AAo] or elephant trunk [ET1] repair) and 21 age‐matched controls (age = 59 ± 10 years; 13 male) were included.Field Strength/Sequence1.5T, 3T, 4D flow MRI.Assessment4D flow MRI was acquired in all subjects. Data analysis included 3D segmentation of TL and FL and voxelwise calculation of forward flow, reverse flow, flow stasis, and kinetic energy as quantitative hemodynamics maps.Statistical TestsAnalysis of variance (ANOVA) or Kruskal–Wallis tests were performed for comparing subject groups. Correlation and Bland–Altman analysis was performed for the interobserver study.ResultsPatients with rTAAD presented with elevated TL reverse flow (AAo repair: P = 0.004, ET1: P = 0.018) and increased TL kinetic energy (AAo repair: P = 0.0002, ET1: P = 0.011) compared to controls. In addition, TL kinetic energy was increased vs. patients with TBAD (AAo repair: P = 0.021, ET1: P = 0.048). rTAAD was associated with higher FL kinetic energy and lower FL stasis compared to patients with TBAD (AAo repair: P = 0.002, ET1: P = 0.024 and AAo repair: P = 0.003, ET1: P = 0.048, respectively).Data ConclusionQuantitative maps from 4D flow MRI demonstrated global and regional hemodynamic differences between DAD patients and controls. Patients with rTAAD vs. TBAD had significantly altered regional TL and FL hemodynamics. These findings indicate the potential of 4D flow MRI‐derived hemodynamic maps to help better evaluate patients with DAD.Level of Evidence: 3Technical Efficacy Stage: 1J. Magn. Reson. Imaging 2020;51:1357–1368.