Primary aortic coarctation repair in adolescents and adults

Optimal management of primary aortic coarctation in adolescents and adults remains controversial. We assess early and late mortality of repair, longitudinal antihypertensive regimens, and freedom from reintervention for repair-related complications.

From January 1, 1999, to July 1, 2023, 110 adolescents or adults, mean age 39 ± 16 years, underwent primary aortic coarctation repair at Cleveland Clinic. Patients were grouped by repair strategy: stented (60, 55%), grafted (interposition graft or extra-anatomic bypass; 36, 33%), or other (14, 13%). Longitudinal antihypertensive regimens were assessed parametrically. Freedom from reintervention and survival were assessed by the Kaplan-Meier method. Median follow-up for survival was 9.2 years.

One patient (0.91%) died in-hospital. Major morbidity included stroke (2/107, 1.9%), tracheostomy (2/107, 1.9%), acute renal failure requiring dialysis (1/108, 0.93%), iatrogenic aortic dissection (1/107, 0.93%), and vascular access complication (1/56, 1.8%). Prevalence of patients requiring zero antihypertensive medications postoperatively peaked within 2 years. Twelve-year freedom from reintervention was 69% in the stented group and 97% in the grafted group (P log-rank = .003). Most reinterventions were for in-stent restenosis of bare metal stents. Overall freedom from reintervention at 1, 5, and 12 years was 91%, 80%, and 76%, respectively. Overall survival was 98%, 95%, and 80% at 5, 10, and 14 years, respectively.

A tailored approach to coarctation repair in adolescents and adults using stented repair when anatomically feasible yields excellent short-term outcomes, but patients require persistent hypertension monitoring and have lower than expected long-term survival. Covered stents or stent grafts are preferred to bare metal stents, which are subject to in-stent restenosis.