Practice variability and outcomes of coil embolization of aortopulmonary collaterals before fontan completion: A report from the Pediatric Heart Network Fontan Cross-Sectional Study

Abstract

Background The practice of coiling APCs before Fontan completion is controversial and published data are limited. We sought to compare outcomes in subjects with and without pre-Fontan coil embolization of aortopulmonary collaterals (APCs) using the Pediatric Heart Network (PHN) Fontan Cross-Sectional Study database which enrolled survivors of prior Fontan palliation. Methods We compared hospital length of stay (LOS) after Fontan in 80 subjects who underwent APC coiling with 459 subjects who did not. Secondary outcomes included post-Fontan complications and assessment of health status and ventricular performance at cross-sectional evaluation (mean 8.6±3.4 years after Fontan). Results Centers varied markedly in frequency of pre-Fontan APC coiling (range 0-30% of subjects, p<0.001). The coil group was older at Fontan (p=0.004), and more likely to have single right ventricular morphology (p=0.054) and pre-Fontan atrioventricular valve regurgitation (p=0.03). The coil group underwent Fontan surgery more recently (p<0.001), was more likely to have a prior superior cavopulmonary anastomosis (p<0.001), and more likely to undergo extracardiac Fontan connection (p<0.001) and surgical fenestration (p<0.001). In multivariable analyses, APC coiling was not associated with LOS (hazard ratio (HR) for remaining in-hospital 0.91, 95% CI 0.70-1.18, p=0.48) or postoperative complications, except more post-Fontan catheter interventions (HR 1.74, 95% CI 1.04-2.91, p=0.03), primarily additional APC coils. The groups had similar outcomes at cross-sectional evaluation. Conclusion Management of APCs before Fontan shows marked practice variation. We did not find an association between pre-Fontan coiling of APCs and shorter post-operative hospital stay or with better late outcomes. Prospective studies of this practice are needed.

Aortopulmonary Collateral Flow is Related to Pulmonary Artery Size and Affects Ventricular Dimensions in Patients After the Fontan Procedure

“…Remarkably, APC flow was related to smaller pulmonary artery size, suggesting that small pulmonary arteries may represent a stimulus for the development of APCs in Fontan patients, a phenomenon that has been previously discussed in patients after the Glenn-operation [12], but has never been described in Fontan patients. When being detected by cardiac catheterization, many centres routinely perform interventional embolization of APCs in SV patients [13]. According to our results, APC embolization alone in the presence of small pulmonary arteries would only treat the symptom and not the cause.…”

Coronary Artery Bypass Grafting in Single-Ventricle Patients Palliated with Fontan Procedure: Future Consideration

“…The incidence of LIMA versus RIMA coiling is poorly described in the literature. A Pubmed search revealed many articles investigating pre-Fontan coiling of APCs without clear specification of the vessel(s) being coiled [3,4,15]. A study designed to evaluate this incidence would be a great start.…”

Acute Effects of Embolizing Systemic-to-Pulmonary Arterial Collaterals on Blood Flow in Patients With Superior Cavopulmonary Connections

“…None of these strategies are based on objective data because such data do not exist. 10 Presently, there are no published data exploring the question of how effective embolization is at reducing collateral flow.…”

“…[6][7][8][9] Currently, there is a wide variation in the practice of transcatheter embolization of SPCs before Fontan surgery. 10 Some centers routinely embolize SPC, whereas others do not, and in some centers, selective embolization is performed based on some combination of angiographic grading and hemodynamic assessment. None of these strategies are based on objective data because such data do not exist.…”