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Coarctation of the aorta in adults: do we need surgeons?
  1. M J Mullen
  1. Correspondence to:
    Dr Michael J Mullen, Adult Congenital Heart Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK;

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With the introduction of endovascular stents, catheter based intervention in the treatment of aortic coarctation now represents a viable alternative to surgery

Coarctation of the aorta is a common congenital defect, which although normally detected and surgically repaired in childhood may present in adolescence or adulthood, usually in the context of investigation for hypertension. The morphological spectrum of abnormalities range from a discrete stenosis distal to the left subclavian, often with extensive collateral formation, to a hypoplastic transverse arch and aortic isthmus, that typically presents in infancy. In some patients coarctation is caused by a long tubular stenosis of the descending thoracic aorta. The natural history of untreated coarctation is that of premature death from stroke and coronary heart disease or sudden death1–3 and relief of anything but the mildest of obstructions is usually indicated.

The techniques for surgical repair of aortic coarctation have progressively evolved over the past 50 years. In the largest series to date,4 representing 646 operations performed between 1946 and 1981, perioperative mortality was highest in infants, lowest in children aged 1–14 years, before gradually increasing in the adolescent and adult population to a peak of 4.5% in adults > 30 years old. While undoubtedly, improvements in technique have significantly reduced operative risk in younger children, few data are available on morbidity and mortality in adult populations and the technical difficulties which underlie the increased risk will remain.5,6 The most devastating complication of coarctation surgery is paraplegia, related to long cross clamp times and injury to spinal arteries, which occurs in approximately 0.5–1% of cases.7 Other complications include paradoxical hypertension, post-coarctectomy syndrome related to reperfusion of viscera, injury to the phrenic or recurrent laryngeal nerve, and pleural effusion or complications of thoracotomy. Recoarctation and aneurysm formation, although relatively rare in …

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