In newborns and infants the diameter of the femoral artery comprises a significant limitation for catheter interventions. Femoral arterial occlusion is a serious complication that can cause limb length shorteningReference Bloom, Mozersky, Buckley and Hagood 1 and this may preclude further catheter interventions if the occlusion is bilateral. Recoarctation of the aorta is a common complication after a neonatal Norwood procedure for hypoplastic left heart syndrome, with an incidence of 10–36%.Reference Zeltser, Menteer and Gaynor 2 , Reference Zellers 3 Today, surgery is the treatment of choice in young patients with native coarctation of aorta; however, in the case of early recoarctation of the aorta surgery is associated with a higher risk for life-threatening complications and poor results,Reference Ibarra-Pérez, Castañeda, Varco and Walton Lillehei 4 and balloon angioplasty is an effective alternative treatment. Although balloon angioplasty proved to be safe and effective in recoarctation of the aorta after Norwood operation,Reference Cleuziou, Kasnar-Samprec, Horer, Eicken, Lange and Schreiber 5 it may not be safe in the early postoperative period.Reference Forbes, Kim and Du 6 In some patients stent implantation may be a better solution. We present the case of a newborn after a Norwood operation with recoarctation of the aorta, who was successfully treated with a bare metal stent via a 5F Glidesheath Slender (Terumo, Tokyo, Japan) in the early postoperative period.
Case report
A newborn boy, weighing 4.2 kg, with hypoplastic left heart syndrome underwent a Norwood procedure at the age of 9 days. On the 1st day after surgery a catheterisation was scheduled for low arterial oxygenation: SaO2<60% under mechanical ventilation with 100% oxygen and 20 ppm nitric oxide. Diagnostic catheterisation was performed using a regular 4F sheath (Terumo, Tokyo, Japan) from the right femoral artery. Angiography showed a narrowed segment in the left pulmonary artery, at a minimal diameter of 2 mm, with compromised flow to the left lung and a stenosis at the origin of the modified 3.5 mm right-sided Blalock–Taussig shunt. In addition, aortic recoarctation of the aorta was seen at the distal end of the neoaortic arch anastomosis, with a peak invasive pull-back gradient of 20 mmHg and a minimal aortic diameter of 2–3 mm (Fig 1a). The findings were discussed within the Heart Team and repeated surgery at this stage was thought to be associated with a high risk. As severe desaturation was the leading clinical sign, two Coroflex®Blue 4×8 mm stents (B. Braun, Melsungen, Germany) were implanted through a 4F sheath: the first one into the narrowed left pulmonary artery segment and the second one proximally into the modified Blalock–Taussig shunt. The recoarctation of the aorta was left untouched as balloon angioplasty and stent implantation into the aorta were estimated to be high-risk procedures on the 1st day after surgery. On day 5 after the Norwood operation, arterial oxygen saturation was 78–80%, but symptoms of prerenal acute kidney failure were observed and the decision for stent implantation into the aortic isthmus was made by the Heart Team. First, stent implantation into the recoarctation of the aorta was attempted via antegrade venous access; however, because of haemodynamic instability and very low arterial oxygen saturation, eventually, the retrograde arterial access was used again. A 5F Glidesheath Slender (Fig 2a) was introduced into the right femoral artery under ultrasound guidance. A Cook Formula 414 stent (6×12 mm) (Cook Medical, Bloomington, Indiana, United States of America) was delivered over a 0.014′ guide wire. Positioning and stent dilation were controlled with fluoroscopy and contrast injections via a catheter that had been advanced antegradely into the ascending aorta. After Stent implantation into the aortic isthmus (Fig 1b), there was no residual gradient. The clinical status of the child improved significantly. No serious complications were recorded. A color Doppler examination performed 1 week after the intervention showed normal pulsatile flow within the right femoral artery.
Figure 1 ( a ) Angiographic depiction of the aortic arch showing a narrowed segment at the level of the aortic isthmus. The peak invasive pull-back gradient was 20 mmHg. ( b ) After implantation of a Cook Formula 414 Stent (6×12 mm) there was no residual gradient. LPA=left pulmonary artery; re-CoA=recoarctation of the aorta.
Figure 2 ( a ) The Glidesheath Slender 5F (Terumo, Tokyo, Japan). ( b ) In our bench test with the Cook Formula 414 Stent (6×12 mm) dilatation to a maximal diameter of 12 mm was possible. ( c ) The outer diameter of the Glidesheath Slender 5F is significantly smaller than the outer diameter of a regular 5F sheath. The inner lumen is compatible with 5F catheters whereas the outer diameter is similar to a regular 4F sheath. Source: Modified from Terumo Corporation, Japan.
Discussion
This case report shows that stenting of a recoarctation of the aorta early after a Norwood operation performed with a Cook Formula 414 stent (6×12 mm) through a 5F Glidesheath Slender in the femoral artery is feasible and the aorta was effectively widened. This stent can be expanded up to 12 mm (Fig 2b). If larger vessel diameters are needed later on in life, the options are either a surgical augmentation of the aorta, or a “cracking” of the stent with a 14 mm high-pressure balloon, possibly under protection with a covered stent.
The Glidesheath Slender is an innovative sheath with a thinner wall and hydrophillic coating. The inner diameter is compatible with 5F catheters whereas the outer diameter is similar to that of a regular 4F sheath (Fig 2c), which is used today in newborns for arterial access during diagnostic or interventional catheterisations. The Formula 414 (6×12 mm) Stent requires, minimally, a 5F inner sheath diameter. The Glidesheath enables performing life-saving interventions in very small, critically ill children with a 1F-less outer sheath diameter. Possibly, the risk for scarring and occluding the femoral vessels is lower with this approach. Although there are no available data presenting results of using Glidesheath Slender in small children, the initial experience with this sheath in obtaining radial access in adults is promising, and shows that Glidesheath Slender does not kink more easily compared with the regular sheaths.Reference Aminian, Dolatabadi and Lefebvre 7 The alternative option would be the carotid artery approach using surgical cut-down. In the case of a patient who weighs over 4 kg, introducing the 5F or even the 6F sheath into the carotid artery seems to be possible.
Recoarctation of the aorta occurs after Norwood operation.Reference Zeltser, Menteer and Gaynor 2 , Reference Zellers 3 Balloon angioplasty is the treatment of choice in our unit in small patients.Reference Cleuziou, Kasnar-Samprec, Horer, Eicken, Lange and Schreiber 5 Balloon angioplasty, however, results in acceptable permanent aortic widening only in 2/3 of the treated patients.Reference Mann, Goebel and Eicken 8 In older children, adolescents, or in adults recoarctation of the aorta can be treated effectively with stents, dilatable to adult-sized aorta.Reference Eicken, Pensl and Sebening 9 , Reference Zanjani, Sabi and Moysich 10
In our patient the native aorta had a diameter of 6 mm; hence, the only options were a surgical re-do, a balloon angioplasty, or a stent implantation. The decision of the Heart Team was against early surgical re-do as the haemodynamic state of the patient was critical. Early balloon angioplasty was thought to be a high-risk intervention. Stent implantation was performed with the smallest available stent with highest potential for diameter augmentation.
Conclusion
In conclusion, we report on a newborn in whom recoarctation of the aorta was stented in the early postoperative period after the Norwood procedure. To reduce the risk of femoral arterial occlusion the stent was implanted via 5F Glidesheath Slender sheath.
Acknowledgements
The authors thank Dr Andreas Eicken and Prof. Peter Ewert for the help in preparing the article.
Financial Support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008, and has been approved by the institutional committees.
