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Primary Aortic Coarctation Diagnosed in the Older Patient: Endovascular Treatment with Thoracic Covered Stents
Keith B. Allen1, A. Michael Borkon1, John Forman2, Sanjay G. Khicha3, Alessandra Puggioni4, Chandrahas Patel4, Steve Laster1, Sanjeev Aggarwal1, J. Russell Davis1.
1St. Luke's Hospital, Mid America Heart & Vascular Institute, Kansas City, MO, USA, 2Freeman Health System, Joplin, MO, USA, 3Wichita Surgical Specialists, Wichita, KS, USA, 4Scottsdale Healthcare System, Scottsdale, AZ, USA.
OBJECTIVE: Primary aortic coarctation (PAC) has been managed in younger patients with uncovered stents, however, in older adults this may be associated with an increased incidence of complications, particularly aortic dissection or rupture. We describe the use of covered thoracic stents to successfully manage previously undiagnosed PAC in older adults.
METHODS: From 2011-2012, PAC was identified in five adult patients at four centers. 
Endovascular management included covered thoracic stents (CTAG, Gore) by themselves or in combination with abdominal aortic extension cuffs (Excluder Cuffs, Gore). Demographics, operative details, procedural complications and follow up were retrospectively reviewed.
RESULTS: Covered stents were successfully deployed in all patients (4 females/1 male). Average age was 62 (range 44-76). Two patients were asymptomatic while three patients presented with ischemia (cerebral, colonic, and lower extremity). Covered thoracic stents were delivered through open femoral exposure; two patients required additional abdominal aortic extension cuffs. Left subclavian artery was preserved in all patients. Graft deployment was facilitated using 30mg of adenosine to obtain transient asystole in four patients. Balloon dilatation was not performed prior to graft placement, however grafts were dilated post deployment. There were deaths, spinal cord ischemia, or vascular access morbidity. Following treatment, pressure gradient across the PAC was zero in all patients. 
Average length of stay was 4 days (range 2-5). With follow up of 6 to 25 months, all patients are alive and well with stable endografts by computed tomography. 
CONCLUSIONS: The treatment of primary aortic coarctation in adults using covered stents is feasible and may reduce the risk of aortic disruption, particularly in older patients, when compared to uncovered stents.
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