McMahon CJ, Peterson D, El Said H. Current Status of Patent Ductus Arteriosus Stenting: An International Practice-Based Study. Pediatric Cardiology. 2026. doi:10.1007/s00246-026-04236-w.
PubMed: https://pubmed.ncbi.nlm.nih.gov/41894016/
Take-Home Points
- This international survey captured responses from 138 interventional pediatric cardiologists across North America, Europe, Asia, the Middle East, and Latin America regarding contemporary PDA stenting practices.
- Marked variability exists in virtually every aspect of PDA stent management, including prostaglandin (PGE) weaning, antiplatelet therapy, stent-length selection, access strategy, ECMO availability, and surgical backup.
- Aspirin monotherapy (46%) and dual antiplatelet therapy with aspirin plus clopidogrel (45%) were used almost equally, highlighting the lack of consensus regarding thromboprophylaxis.
- Carotid access has become mainstream, with 45% of operators using a percutaneous carotid approach and 24% employing carotid cutdown.
- Ductal spasm (87%), thrombosis (51%), left pulmonary artery “shutdown” (36%), and ductal dissection (33%) were the most commonly encountered complications.
- Most operators continue to favor a conventional Norwood strategy for standard-risk HLHS (69%), while only 15% routinely favor primary hybrid Stage I palliation.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
Few developments have transformed neonatal congenital heart intervention as dramatically as patent ductus arteriosus (PDA) stenting. What began two decades ago as an innovative alternative for highly selected patients has rapidly evolved into a mainstream therapy that, in many institutions, has largely replaced the modified Blalock-Taussig-Thomas shunt for duct-dependent pulmonary blood flow. Yet as PDA stenting has matured, an interesting paradox has emerged: despite widespread adoption, many aspects of procedural and post-procedural management remain remarkably undefined.
The survey by McMahon and colleagues provides perhaps the clearest snapshot yet of contemporary international PDA stent practice. Rather than addressing outcomes, the study asks a different and arguably more revealing question: how are operators performing these procedures in real-world practice? The answer is striking. Across nearly every domain examined, substantial heterogeneity exists.
This variability begins before the procedure even starts.
Management of prostaglandin infusion remains one of the most debated aspects of PDA stenting. Operators must balance competing priorities. Continuing prostaglandin preserves ductal patency and reduces the risk of sudden ductal closure. Conversely, maintaining prostaglandin may increase ductal tortuosity and complicate procedural planning. The survey demonstrates that no dominant strategy has emerged. Some operators routinely discontinue prostaglandin, others titrate according to oxygen saturation and clinical status, while a smaller group continues low-dose infusions until wire traversal is achieved. The absence of consensus in an area so fundamental underscores how little evidence currently guides practice.
Equally revealing are the findings regarding antiplatelet therapy. One might assume that after years of PDA stenting experience, a standard thromboprophylactic regimen would have emerged. Instead, the field appears almost evenly divided. Approximately half of respondents prescribe aspirin alone, while the other half use dual antiplatelet therapy with aspirin and clopidogrel. Platelet function testing is rarely performed. Such divergence reflects the reality that current decision-making is driven more by institutional preference than by robust prospective data.
For interventional cardiologists, perhaps the most interesting observation is the widespread adoption of carotid access. Historically viewed as unconventional, carotid access has evolved into a procedural workhorse for complex ductal anatomy, particularly vertical and tortuous ducts that challenge femoral approaches. Nearly half of all respondents now employ percutaneous carotid access. This finding reflects one of the most important technical shifts in contemporary PDA intervention: the recognition that optimal access can be as important as stent selection itself.
The survey also provides an unusually candid glimpse into procedural complications. Ductal spasm was reported by nearly nine out of ten operators, making it almost a universal procedural experience. Thrombosis, left pulmonary artery compromise, and ductal dissection were also frequently encountered. Importantly, these findings should not be interpreted as evidence that PDA stenting is unsafe. Rather, they highlight the substantial technical complexity of the procedure and the learning curve required to perform it successfully. The fact that most operators noted declining complication rates with increasing experience reinforces the importance of institutional expertise and procedural volume.
One of the most concerning findings relates to resource availability. More than one-third of respondents reported practicing in centers where ECMO was never immediately available during PDA stenting procedures. Similarly, congenital surgical standby varied considerably among institutions. This observation raises important questions about minimum resource requirements for PDA stent programs. While PDA stenting generally demonstrates outcomes comparable to, and in some studies superior to, surgical shunting, procedural catastrophes remain possible. A framework defining optimal institutional readiness may become increasingly important as PDA stenting continues to expand globally.
The survey’s insights into HLHS management are equally informative. Despite growing enthusiasm for hybrid strategies, conventional Norwood palliation remains the preferred approach among most respondents. Nearly 70% favored a standard Norwood operation for average-risk patients, whereas only 15% routinely selected a primary hybrid Stage I strategy. This finding suggests that, despite significant advances in hybrid techniques, most specialists continue to regard surgical reconstruction as the benchmark approach for standard-risk HLHS. Hybrid palliation appears to remain largely reserved for selected high-risk populations rather than serving as a universal alternative.
Interstage management after Norwood also revealed substantial practice variation. Although the majority of respondents discharge patients home with structured monitoring, nearly one-third maintain prolonged inpatient surveillance for selected or all patients. These findings are particularly relevant given the well-established impact of home-monitoring programs on reducing interstage mortality. The variation likely reflects differences in institutional resources, outpatient infrastructure, socioeconomic considerations, and regional healthcare delivery models.
Perhaps the most important message from this survey is not that clinicians disagree, but that the field has advanced faster than the evidence base supporting it. PDA stenting has evolved from an innovative procedure to standard practice, yet many of the operational details continue to rely on expert opinion, institutional culture, and procedural experience. This is not uncommon in rapidly evolving interventional disciplines, but it highlights an urgent need for multicenter registries and prospective studies.
The congenital community has successfully conducted collaborative investigations addressing surgical shunts, hybrid palliation, and interstage management. PDA stenting is now mature enough to deserve similar rigor. Questions regarding prostaglandin management, antiplatelet therapy, access selection, stent sizing, and resource requirements are ideally suited for multicenter research efforts capable of generating evidence-based recommendations.
Ultimately, this survey captures a field in transition. PDA stenting is no longer an emerging technology; it is established therapy. Yet the substantial practice variation documented by McMahon and colleagues demonstrates that important questions remain unanswered. The next stage in the evolution of PDA stenting will not be widespread adoption, that has already occurred. Rather, it will be achieving consensus regarding how the procedure is best performed.
Clinical Perspective
International PDA stenting practice demonstrates substantial heterogeneity in prostaglandin management, antiplatelet therapy, access strategy, procedural planning, and institutional backup resources. Although PDA stenting is now a mainstream alternative to surgical shunting for duct-dependent pulmonary blood flow, the absence of standardized approaches highlights the need for prospective multicenter registries and consensus guidelines to optimize outcomes and reduce practice variability.
