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Vol. 73. Issue 10.
Pages 859-861 (October 2020)
Vol. 73. Issue 10.
Pages 859-861 (October 2020)
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Ductal stenting in congenital heart disease with duct dependent pulmonary blood flow
Stent ductal en cardiopatía congénita con flujo pulmonar dependiente del ductus
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Laura Marfil-Godoya, Gerard Martí-Aguascaa, Queralt Ferrer-Menduiñab, Gemma Giralt-Garcíab, Pedro Betrián-Blascoa,
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pedrobetrian@yahoo.es

Corresponding author:
a Unidad de Hemodinámica Pediátrica, Hospital Universitario Materno-Infantil Vall d’Hebron, Universidad Autónoma, Barcelona, Spain
b Unidad de Cardiología Fetal y Neonatal, Hospital Universitario Materno-Infantil Vall d’Hebron, Universidad Autónoma, Barcelona, Spain
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Tables (2)
Table 1. Patient characteristics
Table 2. Procedure and outcomes
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To the Editor,

Stenting of ductus arteriosus in patients with congenital heart disease and duct-dependent pulmonary flow has a long history and validated outcomes.1,2

Our objective was to retrospectively review our experience of this technique. We collected cases of patients born between January 2008 and July 2019, who had been discussed at medical-surgical meetings and referred for ductal stenting based on their underlying heart defect, comorbidities, and ductal anatomy. A total of 32 neonates were included.

Table 1 shows the patients’ characteristics; the most common defect was pulmonary atresia with intact ventricular septum (PAIVS), with 7 cases.

Table 1.

Patient characteristics

Sex
Female  14 
Male  18 
Birth weight, g  3090 (1375-3870) 
Gestational age, wk  38 (30-40) 
Age at catheterization, d  15 (4-165) 
Heart disease
PAIVS 
DORV+PS 
TA 
PA+IVC 
PS 
TA+PS 
Ebstein anomaly 
Previous procedures
Rashkind 
PVP 
Shunt 
Scheduling
Elective  26 
Urgent 
Initial Nakata index  129 (82-168) 
Ductus
Position
Transverse  15 
Isthmus  13 
Brachiocephalic trunk 
Left subclavian 
Morphology   
Tortuous  18 
Straight  14 
Length  15mm (9-26) 
Diameter, mm
Maximum  3,50 (1–5.5) 
Minimum  1 (0.2-3) 
Peripheral pulmonary stenosis 

DORV, double outlet right ventricle; IVC, interventricular communication; PA, pulmonary atresia; PAIVS, pulmonary atresia with intact ventricular septum; PS, pulmonary stenosis; PVP, pulmonary valvuloplasty/valvulotomy; TA, tricuspid atresia; TF, tetralogy of Fallot.

Values are expressed as absolute number of cases or median (range).

We provided prostaglandin E1 at the dose required to achieve preprocedure saturations of 70% to 75%. For patients with possibly transient (days to at least a week) duct dependence (such as PAIVS, pulmonary stenosis following valvuloplasty, or Ebstein anomaly), we waited 2 to 3 weeks before performing the procedure; in all other cases, it was performed within the first 7 to 10 days.

The location and characteristics of the ductus (eg, tortuosity or peripheral pulmonary stenosis) are prognostic factors for procedural success and duration,3 allowing a distinction to be made between complex and relatively noncomplex (normally-positioned and straight) cases.

It is not uncommon to find peripheral pulmonary stenosis (25%) due to the presence of ductal tissue in the branches, which in severe cases requires the placement of longer stents to fully cover the ductus and also treat the peripheral stenosis.4

Table 2 provides information on the procedure and follow-up. The procedure was always carried out under general anesthetic. In normally-positioned ductus, access was usually via the femoral artery using a 4-Fr long sheath for implantation. In other locations, access was via the femoral vein with transcardiac passage of a 5–6-Fr guide catheter or a 4-Fr long sheath, plus access via the carotid artery with a 4-Fr short sheath. Fluoroscopy and procedure times decreased with experience, and are currently very short, especially in noncomplex ductus cases; the difference in times between complex and noncomplex cases was not statistically significant, due to the sample size.

Table 2.

Procedure and outcomes

Implantation
Femoral artery
4-Fr long sheath  15 
5-Fr guide catheter 
Femoral vein
5–6-Fr guide catheter  12 
4-Fr long sheath 
Carotid artery
4-Fr short sheath 
Number of stents  1 (1-4) 
Type of stent
Coronary, bare metal  24 
Coronary, drug-eluting 
Associated procedures
Rashkind 
Patent foramen ovale stent 
Pulmonary valvuloplasty 
Procedure time, min
Overall  165 (42-296) 
Since 2014
Normal ductus  65 (51-77) 
Complex ductus  106 (58-210) 
Fluoroscopy time, min
Overall  34 (8.38-79) 
Since 2014
Normal ductus  14 (12-14) 
Complex ductus  26.2 (17-68) 
SaO2(%)
Initial saturation  77 (61-92) 
Final saturation  92 (72-100) 
Procedural success  30 (94%) 
Complications
End not covered 
Stent thrombosis 
Stent straightening 
Intubation time, h  13.5 (0-96) 
ICU time, d  3 (0-56) 
Redilatations
No. of redilatations 
Days until stenting  145 (22-273) 
Nakata index after stenting  256 (155-362) 
Need for shunt 
Time between stenting and first surgery, d  195 (82-539) 
Stenting as final therapy
Patients 
Follow-up time, y  1-12 
Patency  1/5 

ICU, intensive care unit; SaO2, oxygen saturation.

Values are expressed as absolute number of cases or median (range).

Our patients required a median 13 hours’ intubation and 3 days’ stay in the ICU after the procedure.

The overall success rate was 94% but rose to 100% for cases after 2014. The unsuccessful cases (2/32) corresponded to the initial phase of the series and were due to lack of guidewire stability in complex cases.

The stents used were coronary stents, with a median 1 stent per patient; the last 8 stents implanted were drug-eluting stents to reduce neointimal growth.

Initially, as thromboprophylaxis, we used enoxaparin for 48hours, followed by aspirin. Currently, with drug-eluting stents, we use enoxaparin plus aspirin for 48hours and then switch to aspirin plus clopidogrel.

The mortality rate was 0%. There were no significant vascular complications, and the prevalence of complications in the whole series was 13%, which decreased to 8% in procedures performed after 2014. Complications consisted of the following: need for recatheterization in the days after the procedure due to uncovered ductal ends (1 aortic and 1 pulmonary, the first 2 patients in the series), an early stent thrombosis not requiring additional flow (PAIVS with previous valvulotomy, with improvement in pulmonary flow), and 1 case of straightening of the aortic end of the stent, that interfered with the aortic wall and required surgical removal.

Surgical shunts were created in 2 patients with tricuspid atresia who underwent ductus stenting as neonates, because ductal flow remained insufficient, and Glenn procedure was ruled out or delayed. The first of these was in a premature conjoined twin, weighing 1375g at birth, at 3 months after stenting (without previous stent dilatation). The second was in a patient who weighed 2060g at birth, at 1.8 years (after maximal stent dilatation).

Six angioplasties were performed during the period analyzed: in 2 patients with comorbidities causing a progressive increase in pulmonary pressure and consequent reduction in ductal flow, the stents were dilated to adapt to the new hemodynamics; in another, with growth, the ductus had stretched due to traction resulting in the aortic end having incomplete coverage (angioplasty with stent); in the 3 others, during surgical planning, it was decided to postpone the procedure and instead to dilate to maintain saturations in the correct range while waiting.

The median time to surgery was 195 days in the 25 patients who underwent surgery; 5 patients had a stent as their final treatment (2 pulmonary stenosis, 3 PAIVS).

Presurgical pulmonary artery branch growth was favorable, increasing from a Nakata index of 123 to 256 mm2/m2; on bivariate analysis with the Student t-test, the P value was < .01.

In conclusion, stenting of ductus arteriosus in patients with congenital heart disease and duct-dependent pulmonary flow is a safe technique with a success rate in our series of 100% in all situations after 2014. The procedure is well tolerated by patients, has short intubation times and ICU stays, and allows good branch development and the option to adjust flow to the initial situation with subsequently dilatation if the surgical plan or hemodynamic situation changes. Our recent mortality and morbidity (0% and 8%) compare well with the reported rates from the international registry of surgical shunts (7.2% and 13.1%)5 and are in line with publications from other authors.6 Currently, the technical improvements and standardization of the procedure give reproducible results, allowing ductal stenting to be considered as a first-line option for all patients who have congenital heart disease with duct-dependent pulmonary flow and need for additional pulmonary flow.

References
[1]
F.E. Udink Ten Cate, N. Sreeram, H. Hamza, H. Agha, E. Rosenthal, S.A. Qureshi.
Stenting the arterial duct in neonates and infants with congenital heart disease and duct-dependent pulmonary blood flow: a multicenter experience of an evolving therapy over 18 years.
Catheter Cardiovasc Interv., 82 (2013), pp. E233-E243
[2]
G. Santoro, G. Gaio, L. Giugno, et al.
Ten-years, single-center experience with arterial duct stenting in duct-dependent pulmonary circulation: early results, learning-curve changes, and mid-term outcome.
Catheter Cardiovasc Interv., 86 (2015), pp. 249-257
[3]
D. Schranz, I. Michel-Behnke, R. Heyer, et al.
Stent implantation of the arterial duct in newborns with a truly duct-dependent pulmonary circulation: a single-center experience with emphasis on aspects of the interventional technique.
J Interv Cardiol., 23 (2010), pp. 581-588
[4]
P. Betrián Blasco, G. Marti Aguasca, Q. Ferrer Menduiña.
Ductal stenting and pulmonary artery stenosis.
Rev Esp Cardiol., 73 (2020), pp. 578
[5]
O. Petrucci, S.M. O’Brien, M.L. Jacobs, et al.
Risk factors for mortality and morbidity after the neonatal Blalock-Taussig shunt procedure.
Ann Thorac Surg., 92 (2011), pp. 642-651
[6]
D.M. Bouceck, A.M. Qureshi, B.H. Goldstein, et al.
Blalock-Taussig shunt versus patent ductus arteriosus stent as first palliation for ductal-dependent pulmonary circulation lesions: A review of the literature.
Congenit Heart Dis., 14 (2019), pp. 105-109
Copyright © 2020. Sociedad Española de Cardiología
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