title: Ultra-high-pressure balloon angioplasty for treatment of resistant stenoses within or adjacent to previously implanted pulmonary arterial stents.
abstract: BACKGROUND
  Stents are essential tools in the management of pulmonary arterial (PA) stenosis in patients with congenital heart disease. Although stents can usually be reexpanded as children grow, resistant in-stent or peri-stent obstruction can complicate the management of PA stents. Angioplasty with ultra-high-pressure (UHP) balloons may facilitate successful treatment of stent-associated PA stenoses that are resistant to high-pressure dilation.
  
  
  RESULTS
  We reviewed patients who underwent UHP angioplasty of in-stent or peri-stent PA stenoses that were resistant to high-pressure redilation. A resistant stenosis was defined as a residual balloon waist during high-pressure redilation of the stent, along with a pressure gradient and/or angiographic stenosis. Thirty-four lesions in 29 patients, including 8 with multiple concentric, overlapping, or adjacent stents, were included. The median age at UHP angioplasty was 9 years, and a median of 4 years had elapsed since unsuccessful high-pressure angioplasty. Thirty-one of the 34 (91% [81% to 100%]) UHP angioplasty procedures were successful in relieving the resistant stenosis. Balloon:waist diameter ratios were conservative (median 1.26), reflecting the ability of UHP balloons to "fracture" nearly all obstructions. After UHP dilation, lesion diameter increased by a median of 3.1 mm (36%), significantly more than after previous high-pressure dilation (1.3 mm, 19%; P<0.001). In 5 lesions, UHP angioplasty fractured the stent, allowing further vessel expansion. There were no vascular or other complications.
  
  
  CONCLUSIONS
  UHP angioplasty was safe and effective for treatment of stent-related resistant PA stenosis in this series; the ability to fracture maximally expanded stents may extend the utility of stents in the pediatric population.
authors.affiliation: Department of Cardiology, Children's Hospital, Boston, Mass 02115, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Maglione
authors.forename: Lisa
authors.initials: L
authors.lastname: Bergersen
authors.forename: James E
authors.initials: JE
authors.lastname: Lock
authors.forename: Doff B
authors.initials: DB
authors.lastname: McElhinney
mesh_terms: D000293:Adolescent; D000328:Adult; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003251:Constriction, Pathologic; D006330:Heart Defects, Congenital / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D011312:Pressure; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011651:Pulmonary Artery / Q000000981:diagnostic imaging; D011859:Radiography; D012189:Retrospective Studies; D015607:Stents; D017211:Treatment Failure; D055815:Young Adult