Surgical versus percutaneous repair of aortic coarctation in the pediatric population: A systematic review and meta-analysis update

Background: Native coarctation of the aorta (CoA) accounts for 6–8% of congenital heart defects and carries substantial morbidity and mortality if left untreated. Surgical repair and percutaneous interventions (balloon angioplasty and stenting) represent the two principal treatment modalities; however, clinical equipoise persists regarding the optimal strategy for pediatric patients.
Objective: To compare the short- and long-term safety and effectiveness of surgical repair versus percutaneous management (balloon angioplasty and stent implantation) for native aortic coarctation in patients under 18 years of age.
Methods: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and is prospectively registered with PROSPERO (CRD42024549170). A comprehensive search was performed across MEDLINE, EMBASE, CENTRAL, Scopus, LILACS, IBECS, OpenGrey, and international trial registries, without language restriction. Eligible studies included randomized controlled trials (RCTs) and comparative observational studies enrolling pediatric patients (<18 years) undergoing surgical repair, balloon angioplasty, or stent implantation for native or recurrent CoA. Two reviewers independently performed screening, data extraction, and quality appraisal using the Cochrane RoB 2.0 tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies. Primary outcomes were residual pressure gradient, recoarctation, and reintervention rates; safety outcomes included aortic wall injury, aneurysm formation, and operative mortality. Meta-analyses were conducted in R using random- or fixed-effects models as dictated by heterogeneity (I², Chi² test), with pre-specified subgroup and sensitivity analyses. Evidence certainty was graded using GRADE.
Results: Ten studies involving 723 pediatric patients met inclusion criteria. Compared with balloon angioplasty, surgery was significantly associated with a lower incidence of recoarctation (OR 0.43, 95% CI 0.30–0.63, p<0.001), fewer repeat interventions due to recoarctation (OR 0.40, 95% CI 0.27–0.61, p<0.001), and lower residual trans-coarctation gradient in mid- to long-term follow-up (WMD –8.05 mmHg, 95% CI –12.34 to –3.76, p<0.001). Balloon angioplasty was associated with significantly shorter hospitalization (WMD 19.40 days, 95% CI 15.82–22.99, p<0.001). No significant differences were observed in aneurysm formation (OR 0.64, 95% CI 0.26–1.57, p=0.33), perioperative mortality (OR 2.57, 95% CI 0.87–7.61, p=0.09), or immediate residual gradient (WMD –1.66 mmHg, 95% CI –4.23–0.90, p=0.20). Recent cohort evidence demonstrated that catheter-based interventions carried a significantly higher risk of reintervention compared with surgery (HR 1.8, 95% CI 1.04–3.00, p=0.04), with 10-year event-free survival of 71% for surgery versus 50% for catheter-based treatment (p=0.03). Stenting was identified as the strongest independent predictor of recoarctation (HR 14.653, 95% CI 6.432–33.377, p≤0.001). The certainty of evidence was low to moderate as the majority of included studies were observational studies.
Conclusions: Surgical repair, particularly extended end-to-end anastomosis, is associated with significantly lower rates of recoarctation and reintervention compared with balloon angioplasty in pediatric patients with aortic coarctation, with comparable safety profiles. Percutaneous interventions are associated with shorter hospital stays; however, surgical repair seems to have better durability in the long term. Stenting has excellent immediate hemodynamic results, but is associated with a higher risk of long-term recoarctation, especially in younger patients. The treatment decisions should be individualized based on the patient’s age, anatomy, and the expertise of the institution. High quality randomized controlled trials are urgently needed to strengthen the evidence base.