Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 348 AFRICA well and her weight was 5 kg. There was tight coarctation measuring around 4.5 mm in diameter. We decided to balloon dilate the re-CoA using a Tyshack mini balloon (5 × 20 mm) at 6 atm, resulting in reduction of the pressure gradient across the descending aorta from 50 to 25 mmHg (Fig. 5). By the age of two years her weight was 8.5 kg and she was still suffering from severe coarctation. She was rescheduled for cardiac catheterisation in a hybrid setting for direct access to the aorta, to allow placement of a suitable-sized stent, which could be inflated to adult size, through a large sheath. The distal arch measured 6 mm, while the descending aorta was 5 mm and the coarctant segment was 3 mm in diameter. With the same surgical approach as in the first case, the surgeon fixed the 9-F sheath in the ascending aorta through which we placed a genesis Palmaz stent (10 × 19 mm) (Fig. 6) mounted on a Z Med balloon (10 × 30 mm), inflated to 9 atm. We placed the stent and confirmed its position by hand injections. The balloon was inflated twice and carefully withdrawn. The PG dropped from 50 to 10 mmHg. The patient stayed in the ICU for two days and was discharged home on anti-failure medication. Five-year follow up of both cases The first case had a fracture of the stent, but the patient was stable with no clinical evidence of heart failure and no significant difference between the upper and lower limb pressures, with FS of 25%. We decided that further intervention would not be done unless her clinical condition worsened (Fig. 7). The second case presented with a headache and a high pressure difference between the upper limbs (around 150/100 mmHg) and lower limbs (around 120/70 mmHg). MSCT angiography showed re-stenosis of the stent. Her weight was 18 kg, her aortic arch was 12 mm, the descending aorta at the level of the aorta was 8 mm, and the narrowest stent diameter was 7 mm. We therefore decided to dilate using a Cristal balloon (12 × 40 mm), which was inflated twice to 9 atm in the cath lab (Fig 8). The PG dropped from 54 to 10 mmHg. Discussion Currently, stent implantation is the standard management in adolescents and adults with CoA. It is not a routine therapeutic strategy for infants and young children because of technical difficulties and the limited potential of expansion of the implanted stent. 6 Our cases had re-CoA following surgical repair. Accordingly, the decision to stent this segment seemed to be most appropriate. Previously, using stents for the treatment of postsurgical long- segment coarctation was extremely difficult, as most cases are small infants with small arterial access. It is not feasible to use large delivery systems to implant appropriate-sized stents that Fig. 6. Hybrid procedure in case 2; sheath placed through the ascending aorta and stent placement. Fig. 7. Broken stent. Fig. 5. Balloon dilatation for re-CoA in case 2.