Management of aortic coarctation in adults: endovascular versus surgical therapy.

the most commonly encountered congenital heart diseases, presenting either in isolation or in association with other cardiac defects. It comprises approximately 5-8% of all congenital heart defects and in the majority of cases it is diagnosed and treated during childhood. Aortic coarctation presenting during adult life most frequently represents cases of re-coarctation, following previous transcatheter or surgical therapy, or missed cases of native coarctation. With the emergence and successful employment of transcatheter techniques for relief of aortic CoA in the past two decades, there is broad interest in defining the optimum management method–surgery or endovascular treatment–particularly in the adult population. Surgical repair of CoA was first performed in 1944: therefore, retrospective studies of the surgical results have been influenced by surgical learning curves, operative techniques, age of patient at initial operation, etc. On the other hand, endovascular therapy techniques, available equipment and operator skills have also improved since balloon dilation of aortic CoA was first introduced in 1982 and stent implantation in the early 1990s. In order to compare the results of surgical versus endovascular therapy for adult patients with aortic CoA, mortality as well as morbidity rates should be assessed. Acute morbidity refers to neurological complications, aortic dissection, haemorrhage and heart failure, whereas longterm morbidity refers to the development of aortic dissection and aneurysms, restenosis, persistent hypertension, left ventricular dysfunction and coronary artery disease. When presented with an adult case of CoA, we should take into consideration other coexisting medical conditions, such as diabetes mellitus and atheromatous coronary artery disease, as well as the estimated length of hospital stay, and procedural and hospitalisation costs, before deciding on the optimum treatment method for the individual patient. Unfortunately, prospective randomised control trials of endovascular versus surgical therapy are unavailable in the adult population, whilst only two such studies are available in children. Furthermore, adult patients are different to children, since they may have histological changes of the aortic wall, making them more susceptible to dissection. More importantly, they are more likely to have other comorbidity, placing them at an increased risk of death or complications associated with cardiopulmonary bypass, aortic cross-clamping and hospitalisation in the intensive care unit. The aim of this review is to discuss the different methods employed for the treatment of CoA in adults, and to compare their results based on mortality and morbidity data reported to date.