From Crafoord's End-to-End Anastomosis Approach to Percutaneous Interventions: Coarctation of the Aorta Management Strategies and Reinterventions

Abstract

First described in 1760 by the anatomist Morgagni, coarctation of the aorta (CoA) is a congenital heart defect characterized by narrowing the aorta, typically distal to the left subclavian artery. It accounts for approximately 5-8% of all congenital heart diseases, with an incidence estimated at 4 per 10,000 live births. In 1944, the Swedish surgeon Clarence Crafoord achieved the first successful surgical CoA repair by performing an aortic end-to-end anastomosis on two patients aged 12 and 27 years old. Presently, the most prevalent techniques for surgical repair, particularly in infants and neonates with isolated coarctation, involve resection with end-to-end anastomosis (EEA) and the modified Crafoord technique (extended resection with end-to-end anastomosis (EEEA)). Subclavian flap aortoplasty (SCAP) is an alternative surgical option for CoA repair in patients under two years of age. In cases where the stenosis extends beyond resection and end-to-end anastomosis feasibility, patch aortoplasty (PP) employing a prosthetic patch can augment the stenotic region, especially for older patients. Despite advances in pediatric cardiology and cardiac surgery, recoarctation remains a significant concern after surgical or interventional repair. This comprehensive review aims to provide a thorough analysis of coarctation management, covering the pioneering techniques introduced by Crafoord using end-to-end anastomosis and now extending to the contemporary era marked by percutaneous interventions as well as the recoarctation rate associated with each type.

Keywords: coarctation of the aorta; recoarctation; surgical techniques; transcatheter intervention.

Figure 1

Management algorithm based on the age of the patient. Native CoA: native coarctation of the aorta; Re-CoA: recoarctation of the aorta.

Figure 2

Infant coarctation case. (A) The CT scan highlights the recoarctation, precisely measuring it at 2 mm. (B) Angiography further confirms the recoarctation, showing a trans-coarctation gradient of 40 mmHg. (C) Post-treatment angiography after a 5.5 mm non-compliant Boston balloon dilatation, showing reduced gradient to 16 mmHg.

Figure 3

Adult-onset native coarctation. (A) The angioscanner reveals a 4 mm isthmic coarctation. (B) Confirmation through profile aortic angiography demonstrates a trans-coarctation gradient of 34 mmHg. (C) The patient was successfully treated with a 43 mm XXL Andrastent bare stent mounted on a 14 × 40 mm BiB Balloon, yielding ideal results. (D) The stent was initially placed and later redilated with a larger balloon to optimize its positioning in the aorta. The angiography clearly shows the bare stent properly as opposed to the aortic wall, with no evidence of aortic wall damage.

Figure 3

Adult-onset native coarctation. (A) The angioscanner reveals a 4 mm isthmic coarctation. (B) Confirmation through profile aortic angiography demonstrates a trans-coarctation gradient of 34 mmHg. (C) The patient was successfully treated with a 43 mm XXL Andrastent bare stent mounted on a 14 × 40 mm BiB Balloon, yielding ideal results. (D) The stent was initially placed and later redilated with a larger balloon to optimize its positioning in the aorta. The angiography clearly shows the bare stent properly as opposed to the aortic wall, with no evidence of aortic wall damage.

Figure 4

Pediatric isthmic recoarctation case. (A) Notch on the dilatation balloon. This notch reflects a trans-recoarctation gradient of 20 mmHg. (B) Close-up view of the notch on the dilatation balloon, highlighting the details of the recoarctation. (C) The notch was effectively and completely lifted by a 7 × 20 mm Tyshak balloon. (D) Subsequent angiography reveals good angiographic and hemodynamic results, with a residual gradient of just 9 mmHg.

Figure 4

Pediatric isthmic recoarctation case. (A) Notch on the dilatation balloon. This notch reflects a trans-recoarctation gradient of 20 mmHg. (B) Close-up view of the notch on the dilatation balloon, highlighting the details of the recoarctation. (C) The notch was effectively and completely lifted by a 7 × 20 mm Tyshak balloon. (D) Subsequent angiography reveals good angiographic and hemodynamic results, with a residual gradient of just 9 mmHg.

Figure 5

Infant recoarctation after initial repair (Waldhausen technique). (A) The recoarctation is measured at 3.7 mm, in the context of a horizontal aorta measuring 5.3 mm and a descending aorta of 7.1 mm. The trans-recoarctation gradient is 30 mmHg. Note the absence of a left subcardiac artery. (B) Treatment involved a 6 × 20 mm Tyshak balloon dilatation. (C) Subsequent angiography shows an isthmus diameter of 5.5 mm with no residual gradient, indicating a successful outcome.

Figure 6

Toddler’s recoarctation after initial repair. (A) Isthmus before dilatation, measuring 5.4 mm within a descending aorta and aortic arch of 9.4 mm. (B) Dilatation was achieved using an 8 × 20 mm Tyshak balloon. (C) Post-dilatation control angiography indicates a successful outcome with an isthmus diameter of 7 mm.