Should balloon angioplasty be used instead of surgery for native aortic coarctation?

Editorial Should balloon angioplasty be used instead of surgery for native aortic coarctation? Several groups have used transluminal balloon angioplasty of native aortic coarctation to treat aortic coarctation since the technique was first described in the early 1 980s. Arguments about whether balloon angioplasty is an effective and safe alternative to surgery have been intensified by reports that aneurysms develop at the site of coarctation dilatation. This editorial sets out the evidence that supports the use of balloon angioplasty as an alternative to surgery. Is it effective? The effectiveness of balloon angioplasty can be evaluated by examining the immediate and follow up results in neonates, infants, and children. The immediate effectiveness is judged on the basis of relief of pressure gradients across the coarctation, the lack of need for immediate surgical intervention, and improvement in symptoms. In 67 patients treated by us, peak-to-peak systolic pressure gradients were significantly reduced from 48 (17) (mean (SD)) to 11 (9) mm Hg immediately after balloon angio-plasty.' Our results accord with the results of other workers .23 The reduction in gradient was impressive in all age groups: neonates (s< 30 days), infants (1 to 12 months), and children (> 1 year). Symptoms related to congestive heart failure and/or hypertension, the indications for balloon angioplasty, were relieved'-' and only three (6%) of 47 neonates and infants described in published reports,' and none from our group, required immediate surgical intervention. The results of intermediate term follow up indicate that the excellent reduction in gradient was maintained for the group as a whole, but when results of individual patients were scrutinised, recurrence (generally defined as peak-to-peak gradient > 20 mm Hg) was found to be more common in neonates and infants.lA The restenosis rate was particularly high in the neonates; in a pilot study in 10 consecutive neonates Redington et al found recoarctations in 5 (71%) of the 7 patients in whom there had been excellent relief of obstruction immediately after balloon angioplasty. They concluded that balloon angioplasty for native aortic coarctation was an unrewarding procedure and that their data did not support the continued use of this technique in neonates. In infants the recoarctation rate was high (about 40%) but is not as high as that seen in neonates. I believe that though the rate of recurrence in neonates and infants is high, balloon angioplasty relieves symptoms and spares the infant a thoractomy. Recoarcta-tion can be …