Percutaneous Intervention for Coarctation of the Aorta

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anum Ijaz M.B.B.S., M.D.[2]

Overview

Percutaneous treatment of coarctation of the aorta (CoA) comprises balloon angioplasty (BA) and endovascular stent implantation (SI). Both are established alternatives to open surgical repair for discrete native and recurrent CoA in older children, adolescents, and adults. Stent implantation is the preferred percutaneous modality over BA alone, offering superior hemodynamic results, lower aneurysm rates, and fewer acute complications. Current ACC/AHA and EACTS/STS guidelines endorse endovascular stenting alongside surgery as a Class I option for adults with significant CoA and hypertension. Surgical repair remains the reference standard for neonates, infants, and complex arch anatomy, whereas percutaneous intervention is the treatment of choice for most recurrent CoA and an increasingly accepted first-line option for discrete native CoA in appropriately sized patients.

Historical Perspective

  • 1944: First surgical repair of CoA, performed independently by Crafoord and Gross.[1]
  • 1982–1983: Introduction and wider adoption of transcatheter balloon angioplasty for CoA.[1][2]
  • 1993: O'Laughlin et al. described intravascular bare-metal stent placement in the aorta, beginning the stent era for CoA.[2]
  • 1999: First use of covered stents for CoA, initially for coexistent CoA and aneurysm; indications have since broadened.[2]
  • 2011: The CCISC published the first large multicenter comparison of surgery, stenting, and BA for native CoA, demonstrating superior acute outcomes with stenting.[3]
  • 2015: Intermediate (2-year) COAST results showed sustained obstruction relief with the Cheatham-Platinum (CP) bare-metal stent, though stent fracture and reintervention were noted.[4]
  • 2016: The CP stent and ePTFE-covered CP stent (NuMED Inc.) received FDA approval — the first stents approved specifically for a congenital heart lesion — based on COAST and COAST II data.[5][6]
  • 2021: Long-term (5-year) COAST/COAST II outcomes published — the most comprehensive prospective data on stent durability, fracture, and reintervention predictors.[7]
  • 2022: First randomized trial comparing balloon-expandable CP stents vs. self-expandable nitinol stents, showing comparable short-term safety and efficacy.[8]
  • 2025: Updated ACC/AHA ACHD guideline notes that long-term data suggest higher reintervention risk with stenting than surgery and emphasizes individualized therapy.[9]

Indications

Indications for Percutaneous Intervention

Percutaneous Intervention is indicated for significant CoA, defined by upper-extremity hypertension (resting, ambulatory, or exercise-induced) or left ventricular hypertrophy combined with one of the gradient/anatomic criteria below.[10][9]

Criteria defining hemodynamically significant coarctation
Diagnostic test Index Threshold
Upper- vs. lower-extremity BP Systolic BP difference >20 mmHg
Transthoracic echocardiography Doppler mean gradient >20 mmHg (or >10 mmHg with decreased LV systolic function, significant collateral flow, or aortic regurgitation)
Cardiac catheterization Peak-to-peak gradient >20 mmHg (or >10 mmHg with decreased LV systolic function or significant collateral flow)
MRA / CTA Aortic isthmus ratio
(smallest CoA diameter ÷ descending aorta diameter at the diaphragm)

Indications for Stent Implantation (AHA Scientific Statement)

AHA Scientific Statement 2011, reproduced in Goldstein & Kreutzer, JACC 2021[5]
No. Indication COR LOE
1 Recurrent CoA in patients of sufficient size, with a stent expandable to adult size, and transcatheter gradient >20 mmHg I B
2 Native or recurrent CoA with gradient >20 mmHg IIa B
3 Native or recurrent CoA with gradient IIa C
4 Long-segment CoA with gradient >20 mmHg IIa B
5 After failed balloon angioplasty IIa B
6 Neonates/infants with complex arch obstruction when surgery is high risk (with commitment to future surgical stent removal/enlargement) IIb C

[5]

Indications for Balloon Angioplasty (AHA Scientific Statement)

AHA Scientific Statement 2011, reproduced in Goldstein & Kreutzer, JACC 2021[5]
No. Indication COR LOE
1 Recoarctation with gradient >20 mmHg and suitable anatomy, irrespective of age I C
2 Recoarctation with gradient I C
3 Native CoA as a palliative measure in critically ill patients (severely depressed ventricular function, severe MR, low cardiac output) IIa C
4 Native CoA beyond 4–6 months of age with gradient >20 mmHg and suitable anatomy IIb C
5 Native or recurrent CoA with complex anatomy or connective tissue disease/Turner syndrome (case-by-case) IIb C

[5]

Recommendations for stent implantation in adults

  • 2025 ACC/AHA/HRS/ISACHD/SCAI: Surgical repair or transcatheter stent therapy is recommended for adults with significant CoA and hypertension; therapy should be individualized according to thoracic aorta anatomy, procedural risk, and institutional expertise.[9]
  • 2022 ACC/AHA Aortic Disease: Endovascular stenting or open surgical repair is recommended for significant native or recurrent CoA with hypertension (Class I, LOE B-NR).[10]
  • 2018 AHA/ACC ACHD: Surgical repair or catheter-based stenting is recommended for adults with hypertension and significant native or recurrent CoA (Class I, LOE B-NR); balloon angioplasty alone may be considered when stenting is not feasible and surgery is not an option (Class IIb, LOE B-NR).[11]

Patient Selection

Anatomic and physiologic criteria

  • Discrete CoA at or near the isthmus is the ideal anatomy for percutaneous intervention.[11][5]
  • Femoral artery size must accommodate the delivery sheath, and the stent must be expandable to an adult aortic diameter (minimum ~2 cm).[12]
  • Anatomic severity should be confirmed by CMR or CTA. The 2022 ACC/AHA guideline recommends MRI or CT for initial, surveillance, and follow-up aortic imaging in all CoA patients (Class I, LOE B-NR).[10]

Factors favoring percutaneous vs. surgical approach

Favoring percutaneous intervention:

  • Discrete native or recurrent CoA in adolescents and adults
  • Recurrent CoA after prior surgical repair (BA is the preferred first-line option for recoarctation)[12]
  • Elevated surgical risk (prior sternotomy, comorbidities, advanced age)
  • Patient preference for a less invasive approach

Favoring surgical repair:

  • Neonates and infants (stents cannot be expanded to adult size)
  • Long-segment CoA with associated arch hypoplasia
  • CoA with concomitant intracardiac defects requiring surgical correction
  • Pre-existing large aneurysm at the CoA site requiring excision
  • Proximity of CoA to head and neck vessels precluding safe stent placement[11]
  • Women of childbearing age — surgical repair with excision of paracoarctation tissue may be preferred owing to concerns about tissue integrity during pregnancy[11]

Special populations

  • Pediatric patients: Stent implantation is generally reserved for patients large enough to receive a stent expandable to adult size. In children aged 4–10 years, reintervention rates are high (~52% by 10 years) because of somatic growth requiring stent redilation; BA remains the primary percutaneous option for smaller children with recoarctation.[2]
  • Neonates/infants: BA may serve as a palliative bridge (Class IIa). Stenting is reserved for complex arch obstruction when surgery is high risk, with the understanding that future surgical stent removal or enlargement will be required (Class IIb).[5]
  • Connective tissue disease / Turner syndrome: Percutaneous intervention should be evaluated case-by-case (Class IIb) owing to inherent aortic wall fragility.[5]
  • Near-atretic or acquired atresia: Primary covered-stent implantation is preferred; bare-metal stenting would necessitate a staged approach.[5]

Procedure

Pre-procedural preparation

  • Antiplatelet therapy: Aspirin 325 mg (or clopidogrel 75 mg if aspirin-allergic) before the procedure.[6]
  • Anesthesia: General anesthesia is standard; conscious sedation may be used in select cases.[13]
  • Anticoagulation: IV unfractionated heparin bolus of 100 U/kg (maximum 5000 U) at the start (Class I, LOE B), with an additional 50–100 U/kg as needed to maintain ACT >200 seconds.[14]

Vascular access and hemodynamic assessment

  • Femoral artery and vein access is standard.[13]
  • A complete hemodynamic study is performed, crossing the coarctation retrograde, with pressures proximal and distal to the CoA to document the peak-to-peak gradient.
  • Biplane contrast angiography is performed for measurement of the aortic arch, CoA site, and descending aorta at the diaphragm.[6][13]

Pre-procedural imaging

  • Echocardiography: Assess gradient, LV function, associated bicuspid aortic valve (present in 50–85% of CoA patients; the 2025 ACC/AHA guideline cites >60%), and other congenital defects.[10][9][15]
  • CMR or CTA: Mandatory for delineation of the coarctation site, arch morphology, collateral vessels, and aortic isthmus ratio. CTA is preferred post-stent for in-stent dimensions, stent fractures, and small aneurysms.[10][16]
  • CMR after stenting: Safe and useful for peri-stent tissue, LV hypertrophy, cardiac index, and collateral flow; in-stent visualization is limited (dark-blood imaging assesses patency but not exact dimensions). Ferumoxytol-enhanced bright-blood imaging improves in-stent visualization.[16]
  • Intracranial aneurysm screening: Approximately 10% of adults with CoA harbor intracranial aneurysms. The 2022 ACC/AHA guideline states that screening by MRI or CT "may be reasonable" (Class IIb, LOE B-NR). The 2025 guideline notes that most identified aneurysms are small and stable and that the role of routine screening remains unclear, though baseline screening may be considered.[11][10][9]

Stent and balloon selection

  • Cheatham-Platinum (CP) stent (NuMED Inc.): the only FDA-approved stent for CoA (bare-metal and ePTFE-covered), in lengths of 28, 34, 39, and 45 mm.[6][5]
  • Self-expandable nitinol stents: a valid alternative with comparable short-term safety/efficacy in a randomized trial, though most operators favor balloon-expandable stents for superior radial force to overcome elastic recoil.[8][1]
  • Covered vs. bare-metal: covered stents are preferred for high-risk CoA, near-atretic segments, or pre-existing aortic wall injury; for standard-risk native CoA without wall injury either is acceptable. Covered stents confer some protection against fracture but do not fully prevent late aneurysm.[5][7]
  • Balloon: CP stents are pre-mounted on NuMED BIB (balloon-in-balloon) catheters for controlled, uniform expansion; outer balloon diameters are 12, 14, 15, 16, 18, and 20 mm. The dilated stent diameter should typically not exceed 110% of the distal transverse arch or the descending aorta at the diaphragm.[6]

Stent deployment technique

  1. Advance a long sheath over a stiff guidewire across the CoA, with the wire tip in the left or right subclavian artery or ascending aorta.[13]
  2. Advance the stent/balloon assembly through the sheath into the CoA region.
  3. Deploy by inflating the inner balloon (partial expansion for position confirmation), then the outer balloon (full expansion) - the hallmark of the BIB system.[6]
  4. Rapid right ventricular pacing or other stabilization (e.g., adenosine) may be used to reduce cardiac output and minimize migration.[6]
  5. Repeat inflations may optimize expansion.
  6. Flaring of stent ends with larger balloons may appose the aortic wall in areas of post-stenotic dilation to promote endothelialization.[13]

Post-deployment assessment

  • Obtain pressures in the ascending aorta, immediately above the stent, and in the descending thoracic aorta.
  • Perform post-implantation angiography to assess position, residual gradient, wall integrity, and endoleak (covered stents).[6]
  • Success criteria vary by source: the EACTS/STS 2024 guideline defines success by an acceptably low residual stenosis and residual gradient ; a meta-analysis reported that stenting achieves a residual gradient ≤20 mmHg in ~99.5% of cases vs. ~89.5% with BA alone.[1]
  • Further dilation may be performed per hemodynamic/angiographic findings; additional overlapping covered stents may be placed for endoleak or wall injury proximal/distal to the initial stent.[6]

Post-procedural antiplatelet/anticoagulation protocol

  • Aspirin daily for a minimum of 6 months.[13][6]
  • Patients are often placed on a continuous heparin infusion for systemic heparinization (therapeutic PTT) for ≥12 hours, then transitioned to oral antiplatelet therapy.[14]
  • Pre-existing anticoagulation is resumed in lieu of antiplatelet therapy.[6]
  • The incidence of stent thrombosis in the aortic position is exceedingly low.[14]

Advanced imaging adjuncts

  • 3D rotational angiography (3DRA): CT-like volumetric imaging during catheterization with superior spatial resolution; shows stent impact on adjacent structures, optimizes gantry angles, and can be overlaid on live fluoroscopy. Computational fluid dynamics with virtual stenting has been demonstrated in CoA.[17]
  • Intravascular ultrasound (IVUS): greater accuracy than angiography for the coarctation area, tears, dissection flaps, and residual coarctation; particularly useful in infants.[18]

Complications

Acute complications

Aortic wall injury (intimal tears, dissection, contained rupture) is the most clinically significant acute complication.

  • CCISC acute complication rates: 2.3% for stenting vs. 9.8% for BA vs. 18.1% for surgery.[3]
  • Aortic rupture is rare (~1% in adult stenting meta-analysis) but devastating with high mortality; it can often be managed with an additional covered stent.[19][20]
  • Aortic dissection occurs in ~2% of adult stenting procedures.[19]
  • Stent malposition is unique to SI; the BIB catheter and rapid RV pacing have reduced this risk.[12]
  • Vascular access injury (femoral artery) is recognized, particularly in smaller patients requiring large-bore sheaths.[12]

Late complications

Aneurysm / pseudoaneurysm:

  • Cumulative incidence 6.3% at 5 years in COAST/COAST II.[7]
  • Significantly lower with stenting than BA alone (3.1% vs. 21.4% in CCISC).[3]
  • Covered stents do not confer complete protection; most post-transcatheter aneurysms occur within the first year, with late (>3-year) formation rare but reported.[7][3]

Stent fracture:

  • Cumulative incidence 24.4% at 4–5 years in COAST/COAST II. Independent predictors: age .[7]
  • Covered stents appear to distribute radial force better, reducing fracture risk.[1]
  • No fracture has resulted in loss of stent integrity, embolization, wall injury, or reobstruction in the COAST data.[4]
  • CT angiography with 3D reconstruction is superior to echocardiography and chest radiography for detecting fractures — about one-third are only identifiable on CT.[11]

Restenosis / recoarctation and reintervention:

  • Cumulative reintervention rate 21.3% at 5 years (COAST/COAST II). Independent predictors: age .[7]
  • In adults, reintervention is ~8% at median 29-month follow-up (meta-analysis, 705 patients), with 95.5% performed endovascularly.[19]
  • Younger patients have higher reintervention rates from somatic growth: ~52% by 10 years in children aged 4–10 vs. ~12% in adults.[2]

Persistent hypertension:

  • Hypertension persists in ~50% of patients at 1 year after successful stenting, though the number of antihypertensive medications decreases.[8]
  • Exercise-induced hypertension (peak SBP >210 mmHg in males, >190 mmHg in females) is common and independently associated with LV hypertrophy and cardiovascular events.[9]
  • Given the high prevalence of ASCVD risk factors in this population, the 2025 ACC/AHA guideline recommends a target systolic BP for these patients.[9]

Associated coronary risk

The 2025 ACC/AHA guideline emphasizes that premature coronary artery disease in CoA patients is multifactorial, driven by hypertension, hyperlipidemia, type 2 diabetes, and inherent vascular dysfunction; aggressive cardiovascular risk-factor modification is warranted.[9]

Surveillance after percutaneous intervention

Recommended follow-up intervals (months) by physiological stage
Test Stage A Stage B Stage C Stage D
ACHD cardiologist visit 24 24 6–12 3–6
ECG 24 24 12 12
TTE 24 24 12 12
CMR/CCT 36–60 36–60 12–24 12–24
Exercise test 36 24 24 12

[11]

Note: The 2025 ACC/AHA ACHD guideline (Table 24) updates some intervals: Stage C ACHD cardiologist visits are now every 12 months (previously 6–12), and Stage D ECG and ACHD visit are now every 6 months (previously 12 and 3–6, respectively). The 2025 table includes only three rows (ACHD visit, ECG, TTE) and does not specify CMR/CCT or exercise-test intervals; the 2018 recommendations for those modalities should be followed until updated. The 2025 guideline additionally notes that exercise testing every 5 years is reasonable in CoA patients with hypertension already on antihypertensive therapy, to assess adequacy of BP control.[9]

ACC/AHA Appropriate Use Criteria for post-stent imaging:

  • TTE: appropriate for routine post-procedural evaluation and all surveillance intervals.[21]
  • CMR/CCT: appropriate every 3–5 years in asymptomatic patients to evaluate for arch aneurysm, in-stent stenosis, fracture, or endoleak; may be appropriate every 1–2 years after the first year in patients with no or mild sequelae.[21]
  • CCT is preferred over CMR for in-stent dimensions and fracture detection.[11][16]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Czerny M, Grabenwöger M, Berger T; et al. (2024). "EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ". European Journal of Cardio-Thoracic Surgery. 65 (2): ezad426. doi:10.1093/ejcts/ezad426.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Eriksson P, Pihkala J, Jensen AS; et al. (2023). "Transcatheter Intervention For Coarctation of the Aorta: A Nordic Population-Based Registry With Long-Term Follow-Up". JACC Cardiovascular Interventions. 16 (4): 444–453. doi:10.1016/j.jcin.2022.11.007.
  3. ↑ 3.0 3.1 3.2 3.3 Forbes TJ, Kim DW, Du W; et al. (2011). "Comparison of Surgical, Stent, and Balloon Angioplasty Treatment of Native Coarctation of the Aorta: An Observational Study by the CCISC (Congenital Cardiovascular Interventional Study Consortium)". Journal of the American College of Cardiology. 58 (25): 2664–74. doi:10.1016/j.jacc.2011.08.053.
  4. ↑ 4.0 4.1 Meadows J, Minahan M, McElhinney DB, McEnaney K, Ringel R (2015). "Intermediate Outcomes in the Prospective, Multicenter Coarctation of the Aorta Stent Trial (COAST)". Circulation. 131 (19): 1656–64. doi:10.1161/CIRCULATIONAHA.114.013937.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Goldstein BH, Kreutzer J (2021). "Transcatheter Intervention for Congenital Defects Involving the Great Vessels: JACC Review Topic of the Week". Journal of the American College of Cardiology. 77 (1): 80–96. doi:10.1016/j.jacc.2020.11.019.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Taggart NW, Minahan M, Cabalka AK; et al. (2016). "Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II)". JACC Cardiovascular Interventions. 9 (5): 484–93. doi:10.1016/j.jcin.2015.11.038.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Holzer RJ, Gauvreau K, McEnaney K, Watanabe H, Ringel R (2021). "Long-Term Outcomes of the Coarctation of the Aorta Stent Trials". Circulation. Cardiovascular Interventions. 14 (6): e010308. doi:10.1161/CIRCINTERVENTIONS.120.010308.
  8. ↑ 8.0 8.1 8.2 Sadeghipour P, Mohebbi B, Firouzi A; et al. (2022). "Balloon-Expandable Cheatham-Platinum Stents Versus Self-Expandable Nitinol Stents in Coarctation of Aorta: A Randomized Controlled Trial". JACC Cardiovascular Interventions. 15 (3): 308–317. doi:10.1016/j.jcin.2021.11.025.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Gurvitz M, Krieger EV, Fuller S; et al. (2025). "2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. doi:10.1016/j.jacc.2025.09.006. Unknown parameter |note= ignored (help)
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Isselbacher EM, Preventza O, Hamilton Black J III; et al. (2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. 80 (24): e223–e393. doi:10.1016/j.jacc.2022.08.004.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 Stout KK, Daniels CJ, Aboulhosn JA; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease". Journal of the American College of Cardiology. 73 (12): e81–e192. doi:10.1016/j.jacc.2018.08.1029.
  12. ↑ 12.0 12.1 12.2 12.3 Feltes TF, Bacha E, Beekman RH; et al. (2011). "Indications for Cardiac Catheterization and Intervention in Pediatric Cardiac Disease: A Scientific Statement From the American Heart Association". Circulation. 123 (22): 2607–52. doi:10.1161/CIR.0b013e31821b1f10.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Hamdan MA, Maheshwari S, Fahey JT, Hellenbrand WE (2001). "Endovascular Stents for Coarctation of the Aorta: Initial Results and Intermediate-Term Follow-Up". Journal of the American College of Cardiology. 38 (5): 1518–23. doi:10.1016/s0735-1097(01)01572-8.
  14. ↑ 14.0 14.1 14.2 Giglia TM, Massicotte MP, Tweddell JS; et al. (2013). "Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease: A Scientific Statement From the American Heart Association". Circulation. 128 (24): 2622–703. doi:10.1161/01.cir.0000436140.77832.7a.
  15. ↑ Saengsin K, Gauvreau K, Prakash A (2023). "Comparison of Aortic Stiffness and Hypertension in Repaired Coarctation Patients With a Bicuspid Versus a Tricuspid Aortic Valve". Journal of Cardiovascular Magnetic Resonance. 25 (1): 31. doi:10.1186/s12968-023-00941-0.
  16. ↑ 16.0 16.1 16.2 Fogel MA, Anwar S, Broberg C; et al. (2022). "SCMR/EACVI/ASE/SPR/NASCI Guidelines for the Use of Cardiovascular Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease". Journal of Cardiovascular Magnetic Resonance. 24 (1): 37. doi:10.1186/s12968-022-00843-7.
  17. ↑ Sachdeva R, Armstrong AK, Arnaout R; et al. (2024). "Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement". Journal of the American College of Cardiology. 83 (1): 63–81. doi:10.1016/j.jacc.2023.10.025.
  18. ↑ Mortezaeian H, Khalili Y, Farrokhi M; et al. (2021). "Intravascular Ultrasound for Assessment of Residual Coarctation of the Aorta After Balloon Angioplasty in Infants". Pediatric Cardiology. 42 (2): 442–450. doi:10.1007/s00246-020-02503-y.
  19. ↑ 19.0 19.1 19.2 Nana P, Spanos K, Brodis A; et al. (2025). "A Systematic Review and Meta-Analysis on Stenting for Aortic Coarctation Management in Adults". Journal of Endovascular Therapy. 32 (3): 548–557. doi:10.1177/15266028231179919.
  20. ↑ Erben Y, Oderich GS, Verhagen HJM; et al. (2019). "Multicenter Experience With Endovascular Treatment of Aortic Coarctation in Adults". Journal of Vascular Surgery. 69 (3): 671–679.e1. doi:10.1016/j.jvs.2018.06.209.
  21. ↑ 21.0 21.1 Sachdeva R, Valente AM, Armstrong AK; et al. (2020). "ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease". Journal of the American College of Cardiology. 75 (6): 657–703. doi:10.1016/j.jacc.2019.10.002.
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