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

Abstract

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.

Stenting of the Patent Ductus Arteriosus: A Meta-analysis and Literature Review

“…35,36 It may also ease wire and catheter exchanges, which can be critical in cases of hemodynamic instability or other complications. 38 In addition, Bauser-Heaton et al 36 found that the flip technique was associated with shorter procedure times for highly tortuous PDAs, although this did not reach statistical significance. Although the distance to the patient's airway can pose challenges to the anesthesiology team, it does allow for easy access to lower extremity lines, and the benefits of the overall procedure likely outweigh this difficulty.…”

“…Although there is a paucity of large-scale data on vascular access for PDA stenting, multiple smaller observational studies present promising outcomes for the carotid and axillary arteries, particularly for approaching vertical PDAs through the superior aspect of the aortic arch. 25,30,[35][36][37][38][39][40][41] Bauser-Heaton et al 36 observed that carotid and axillary artery access is more commonly used in highly tortuous PDAs than the femoral artery and that procedural and late complications were similar regardless of the access site. Similarly, Alsawah et al 37 reported that percutaneous carotid access was more commonly used in complex ductal anatomy, and they found that both immediate access-related complications and delayed local complications in these cases were significantly lower than in cases that used the femoral artery.…”

“…37 Partly in an effort to avoid these potentially devastating neurologic consequences, other interventionists have attempted vertical PDA access through the axillary artery. [38][39][40]42 Although subclavian artery injury is possible with axillary artery access, for many years, classic Blalock-Taussig shunts have sacrificed the subclavian artery with no significant long-term complications. 43 This likely represents the reason that interventionists such as Lee et al 39 prefer the axillary approach.…”

“…43 This likely represents the reason that interventionists such as Lee et al 39 prefer the axillary approach. Breatnach et al 38 described a successful series of PDA stenting via the axillary artery in 20 patients, with 3 access-related complications that were managed conservatively without long-term effects (2 partial dissections to the subclavian artery and a right axillary artery pseudoaneurysm). Polat 40 also noted that for vertical PDAs, the axillary approach was associated with significantly shorter fluoroscopy time and total procedure time than the transvenous approach.…”

“…Therefore, there has been a trend toward the increased use of drug-eluting stents, although many institutions continue to use bare-metal stents owing to the lack of robust data regarding drugeluting stent safety. 13,18,20,31,38 Rapamycin-eluting stents have been shown to prolong ductal patency in piglets, although this effect decreases with time. 39,45 However, some concern remains over the potential immunosuppressive effects of drug-eluting stents.…”