[II-PSY2-1] PDA stenting in duct-dependent pulmonary circulation
Keywords:pulmonary atresia, stenting of arterial duct, duct-dependent pulmonary circulation
PDA stenting in duct-dependent pulmonary circulation became an alternative palliative procedure to Blalock Tomas Taussig shunt. Procedural success depends on the preprocedural assessment, selection of the hardware, and meticulous planning. All patients underwent the procedure under intubation anesthesia. The location and morphology of the PDA determined the access to the procedure. Carotid, axillary, femoral artery, or femoral vein approaches were used to stent the PDA based on the type (vertical, semi-vertical, or indirect) and course. A 4 mm diameter stent was chosen for patients weighing > 3 kg and branch pulmonary artery diameters above 4 mm at the hilum, whereas a 3.5 mm diameter stent was chosen for patients < 3.0 kg and branch pulmonary artery diameters of < 4 mm. The length was determined by the angiographic measurement of the PDA. Immediate improvement of systemic saturation and angiographic opacification of the pulmonary arteries are important factors of successful stent deployment. Intravenous unfractionated heparin infusion was given for 12-24 hrs. after the procedure. Oral aspirin was given at 2-3 mg/kg till the next palliative or definitive procedure. Follow-up assessment included clinical, saturation, and pulmonary artery size by transthoracic echocardiogram or computerized tomography in selected cases.
The data was analyzed for the last 150 cases undergoing the procedure from 2015 to 2024. Tetralogy of Fallot with pulmonary atresia, single ventricle with pulmonary atresia, heterotaxy syndrome with pulmonary atresia, and pulmonary atresia with intact septum were included in the study for the PDA stenting. The procedure success was 96%. The PDA stenting procedure was abandoned due to the unfavorable anatomy (bilateral branch PA stenosis) and favorable anatomy for the biventricular repair and duct spasm in the catheterization laboratory. The overall mortality was 10.8 % immediately and during follow-up. Acute stent thrombosis, duct rupture, circular shunt, and associated co-morbid conditions like sepsis are the causes of mortality. Stent migration was present in 2 cases and required additional PDA stenting. Sub-analysis of data showed that there was a change in the pattern of the procedure including continuous infusion of low-dose prostaglandin infusion till the time of the procedure, continuous heparin infusion after the stenting, recruitment of branch pulmonary artery stenosis, and access to the procedure. Second palliation either BTT shunt with PA plasty or BTT shunt alone was done in 3.2% of patients due to suboptimal growth of pulmonary arteries. Early 2nd stage intervention was required for the patients who underwent PDA stenting either palliation or biventricular repair.
The data was analyzed for the last 150 cases undergoing the procedure from 2015 to 2024. Tetralogy of Fallot with pulmonary atresia, single ventricle with pulmonary atresia, heterotaxy syndrome with pulmonary atresia, and pulmonary atresia with intact septum were included in the study for the PDA stenting. The procedure success was 96%. The PDA stenting procedure was abandoned due to the unfavorable anatomy (bilateral branch PA stenosis) and favorable anatomy for the biventricular repair and duct spasm in the catheterization laboratory. The overall mortality was 10.8 % immediately and during follow-up. Acute stent thrombosis, duct rupture, circular shunt, and associated co-morbid conditions like sepsis are the causes of mortality. Stent migration was present in 2 cases and required additional PDA stenting. Sub-analysis of data showed that there was a change in the pattern of the procedure including continuous infusion of low-dose prostaglandin infusion till the time of the procedure, continuous heparin infusion after the stenting, recruitment of branch pulmonary artery stenosis, and access to the procedure. Second palliation either BTT shunt with PA plasty or BTT shunt alone was done in 3.2% of patients due to suboptimal growth of pulmonary arteries. Early 2nd stage intervention was required for the patients who underwent PDA stenting either palliation or biventricular repair.