Duct Stenting Versus Modified Blalock-Taussig Shunt in Neonates With Duct-Dependent Pulmonary Blood Flow

Background Carotid artery (CA) and axillary artery (AA) access are increasingly used for transcatheter stenting of the patent ductus arteriosus (PDA), although reports are limited. Methods The Congenital Catheterization Research Collaborative (CCRC) reviewed multicenter data from infants who underwent PDA stenting via the CA or AA approach from 2008 to 2017, and compared outcomes to those of infants undergoing PDA stenting via the femoral artery (FA) approach. Post‐procedure ultrasound (US) imaging was reviewed. Results Forty‐nine infants underwent PDA stenting from the CA (n = 43) or AA (n = 6) approach, compared with 55 infants who underwent PDA stenting from the FA approach. The PDA was the sole pulmonary blood flow (PBF) source in 61% of infants in the CA/AA cohort, compared with 33% of the FA cohort (p < .01). Ductal tortuosity for CA/AA cohort was Type I (straight) in 10 (20%), Type II (one turn) in 17 (35%), and Type III (multiple turns) in 22 (45%) infants and reflected a greater degree of tortuosity when compared to the FA cohort (p < .01). In 17 infants with CA/AA approach, the “flip technique” was used, and was associated with shorter procedure times for highly tortuous PDA (Type III) patients. Rates of procedural complications were similar across access sites. Most common complications were access site injury (thrombus or bleeding) and stent malposition. No complications were specifically related to the “flip technique.” Conclusions Use of CA and AA approach for PDA stenting was found to be more commonly employed in sole source PBF and highly tortuous PDAs. Procedural modifications such as the “flip technique” may lead to shorter procedure times. CA and AA approaches are associated with a similar burden of procedural or late complications. Post‐procedural surveillance of the CA and AA is suggested, given the incidence of vascular findings on US.

Section: Discussionmentioning

confidence: 59%

“…[1][2][3][4] Recently, two studies comparing surgical BTS to PDA stenting with adjusted analyses to balance the cohorts found that infants palliated with a PDA stent had favorable outcomes. 5,6 PDA stenting was associated with lower mortality and reduced hospital length of stay, albeit with equivalent or higher rates of reintervention.…”

mentioning

confidence: 89%

Use of carotid and axillary artery approach for stenting the patent ductus arteriosus in infants with ductal‐dependent pulmonary blood flow: A multicenter study from the congenital catheterization research collaborative

Bauser‐Heaton

Qureshi

Goldstein

et al. 2019

“…PA diameter was measured at the hilum prior to the origin of the secondary PA branching, with an imaging hierarchy scheme used based on available data (angiography > computerized tomography scan > magnetic resonance imaging > echocardiography). PA diameter at latest follow-up was evaluated using the Nakata index 16 and a "symmetry index" (18), the ratio of the smaller branch PA to the larger branch PA diameter.…”

Section: Discussionmentioning

confidence: 99%

“…15 More favorable primary and secondary outcomes with PDA stent placement versus BT shunt placement were also recently reported in a multi-center study from the United Kingdom. 18 Highly tortuous PDAs can be challenging to stent or deemed to be unsuitable for stent placement in some situations, even by experienced operators. [8][9][10][11] However, the definition of PDA "tortuosity" (it is also noteworthy that the access site for PDA stent deployment changed in four patients).…”

Section: Discussionmentioning

confidence: 99%

Classification scheme for ductal morphology in cyanotic patients with ductal dependent pulmonary blood flow and association with outcomes of patent ductus arteriosus stenting

Qureshi

Goldstein

Glatz

et al. 2019

Objectives To devise a classification scheme for ductal morphology in patients with ductal dependent pulmonary blood flow (PBF) that can be used to assess outcomes. Background The impact of ductal morphology on outcomes following patent ductus arteriosus (PDA) stenting is not well defined. Methods Patients <1 year of age who underwent PDA stenting for ductal dependent PBF at the four centers comprising the Congenital Catheterization Research Collaborative (CCRC) were included. A classification scheme for PDA morphology was devised based on a tortuosity index (TI)—Type I (straight), Type II (one turn), and Type III (multiple turns). A subtype classification was used based upon the ductal origin. Results One hundred and five patients underwent PDA stenting. TI was Type I in 58, Type II in 24, and Type III in 23 PDAs, respectively. There was a significant association between ductal origin and vascular access site (p < 0.001). Procedure times and need for >1 stent did not differ based on TI. Greater TI was associated with pulmonary artery (PA) jailing (p = 0.003). Twelve (11.4%) patients underwent unplanned reintervention, more commonly with greater TI (p = 0.022) and PA jailing (p < 0.001). At the time of subsequent surgical repair/palliative staging, PA arterioplasty was performed in 32 patients, more commonly when a PA was jailed (p = 0.048). PA jailing did not affect PA size at follow up. Conclusions The proposed qualitative and quantitative PDA morphology classification scheme may be helpful in anticipating outcomes in patients with ductal dependent PBF undergoing PDA stenting.

“…Stenting of the ductus arteriosus has been reported as an alternative to BT shunt for palliation of neonates with critical right ventricular outflow tract lesions. [1][2][3] It provides a secure source of pulmonary blood flow while avoiding a surgical procedure and its associated comorbidities. 4,5 It also has the advantage of promoting branch pulmonary artery growth and may provide a more balanced pulmonary vasculature.…”

Section: Introductionmentioning

confidence: 99%

Percutaneous axillary artery approach for ductal stenting in critical right ventricular outflow tract lesions in the neonatal period

Breatnach

Aggarwal

Al-Alawi

et al. 2019

Objectives We aimed to assess the experience using a percutaneous axillary artery approach for insertion of arterial ductal stents in patients with critical right ventricular outflow tract lesions at two tertiary pediatric cardiology centers. Background Patent ductus arteriosus stenting is an accepted palliative alternative to BT shunts for neonates with critical right heart lesions. Access to tortuous ductus' may be challenging via the femoral artery, whereas the carotid artery presents a low risk of stroke. Recently, the axillary artery has been utilized for access in these patients. Methods We performed a retrospective review of neonates who underwent stent placement or angioplasty using percutaneous axillary artery approach at two tertiary care centers from October 2016 to November 2018. Medical records were reviewed to ascertain demographic, clinical, and outcome data. Results Axillary artery access was performed in 20 patients (16 primary ductal stents and 4 re‐interventions) at a median (IQR) procedural weight of 3.4 (3–3.9) kg. Median (IQR) procedural time was 110 (75–150) min. The median (IQR) ICU stay and intubation times were 14 (0–94) hr and 5 (0–40) hr, respectively. There were three access‐related vascular complications which were managed conservatively with no long‐term effects. Two patients subsequently died due to non‐procedure related causes. Conclusions Ductal stenting via a percutaneous axillary artery approach is a viable option in neonates with critical right ventricular outflow tract lesions. This approach provides an additional access site for PDA stenting which may be utilized in patients with vertical duct morphology.