Severe twin–twin transfusion syndrome: outcome after fetoscopic laser ablation of the placental vascular equator

Abstract

Objective To assess the safety and efficacy of a modified fetoscopic laser ablation technique for the management of severe twin-twin transfusion syndrome (TTTS) in a large series of pregnancies.Design Prospective cohort study.Setting Tertiary referral fetal medicine unit.Population Women with pregnancies complicated by severe TTTS (Quintero stage III or IV), before 26 weeks of gestation.Methods Fetoscopic laser ablation of placental anastomoses was performed. The sonoendoscopic approach was used to identify the placental vascular equator and to photocoagulate crossing vessels.Main outcome measures Overall survival, fetal and perinatal mortalities, gestational age at delivery, birthweight, operating time and recurrence of TTTS.Results A total of 77 women underwent the procedure. The mean gestational age at treatment was 20 (range 16-26) weeks. On average, four vessels were ablated during each procedure, with a mean operative time of 15 (range 5-25) minutes. None of the women required a repeat fetoscopic laser treatment for recurrence of the TTTS. There was at least one survivor in 74% (57/77) of pregnancies, and the overall survival rate was 57% (88/154).Conclusions Fetoscopic laser ablation is a safe and effective form of treatment in the management of severe TTTS. The technique of identifying the common villous district of the placenta by ultrasound and photocoagulating any vessels crossing the vascular equator appears to be an acceptable alternative to both the nonselective and highly selective methods described so far. This approach is associated with a short operating time, low likelihood of TTTS recurrence or fetal anaemia and with survival results that are equivalent to previously reported techniques.

Twenty-Five Years of Fetoscopic Laser Coagulation in Twin-Twin Transfusion Syndrome: A Systematic Review

“…One of the studies enrolled was a randomized controlled trial [13]; there were 13 prospective single-center cohort studies [10,12,18,19,20,22,23,24,25,26,28,30,32], 18 retrospective single-center cohort studies [27,29,31,33,34,35,36,37,38,39,40,41,42,43,44,46,47,59], 2 prospective multicenter cohort studies [21,58] and 3 retrospective multicenter cohort studies [45,48,55]. …”

“…After full-text analysis a total of 34 studies were included in the time-based analysis [10,12,13,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]. Twelve studies [5,49,50,51,52,53,54,55,56,57,58,59] presented data overlapping other series, of which one presented data relevant for the technique-based analysis [58].…”

“…These groups were analyzed separately, resulting in 41 subgroups describing survival results for different laser techniques. The non-selective laser technique was used in five series [10,18,19,20,21], 28 series used the selective laser technique [12,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,42,43,45,46,47,48,58], the selective sequential technique was used in five series [12,13,30,41,44], and three series used the Solomon technique [13,46,48]. …”

Fetal and Maternal Complications after Selective Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: A Single-Center Experience

“…Other authors have reported a rate of cerebral lesions following laser of 5.4% [31]. In a series of 77 cases treated with coagulation of all vessels crossing the vascular equator [32], the authors considered the cerebral hemorrhage affecting 4 fetuses (2.6%) as preexisting because it was evident after AR at laser. Since our cases of cerebral damage occurred early on in our experience, we attribute them to the learning curve of the operators involved.…”

Instrumental requirements for minimal invasive fetal surgery

“…3,26,27 There is continuing debate on the selection and order which way the chorionic plate vessels should be coagulated, but is widely accepted that selective laser coagulation along the vascular equator should be attempted when feasible. [28][29][30][31] Selective feticide in complicated monochorionic pregnancies Selective feticide in monochorionic multiples cannot be performed by injection of potassium chloride or xylocain because the substance may embolise to the healthy fetus or the surviving fetus may exsanguinate via the ever-present anastomoses into the feto-placental unit. Vascular embolising agents were abandoned because of high failure rates, 32 probably because of incomplete vascular obliteration or product migration.…”