Cutting balloon angioplasty on branch pulmonary artery stenosis in pediatric patients.
Cobb H, Spray B, Daily J, Dossey A, Angtuaco MJ. Catheter Cardiovasc Interv. 2021 Sep;98(3):526-532. doi: 10.1002/ccd.29803. Epub 2021 Jun 10. PMID: 34110668
Take Home Points:
- Cutting balloon angioplasty (CBA) for pulmonary artery stenosis (PAS) shows moderate medium-term success.
- Patients with TOF/PA/MAPCAs and especially those with genetic syndromes associated with PAS (Williams, Alagille, or arterial tortuosity syndrome) are significantly less likely to have a lasting success following CBA.
- Choosing a maximal balloon diameter as the smallest of either 150% of the distal vessel or 300% of the minimal luminal diameter is associated with sustained success following CBA.
Commentary from Dr. Prsa Milan (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
Cutting balloon angioplasty (CBA) has been used successfully to treat PAS resistant to standard pressure balloons. However, there is little data on long-term outcomes. The authors of this study describe the longest follow-up to date of CBA in PAS at a single institution and identify predictors of a successful outcome.
From 2005 to 2020, 44 patients (median age 20 months and weight 12.4 kg) underwent 148 CBAs on 116 unique pulmonary artery segments. The mean ratio of cutting balloon diameter to minimal luminal diameter (MLD) was 2.51 ± 1.06 (range 1.0-8.0). There was good initial success (≥50% increase in MLD) with an average immediate increase in MLD of 57.3% (CI, 39.0%-75.6%). In addition, there was sustained improvement at a mean follow-up time of 34.3 months (CI, 0-142 months) with an average increase in MLD of 78.7% (CI, 44%-114%). Complications included reperfusion injury in three patients and pulmonary hemorrhage in two, one of whom died from acute pulmonary artery rupture. Unsurprisingly, interventions were less successful in patients with TOF/PA/MAPCAs and those with genetic syndromes associated with branch PAS (Williams, Alagille, or ATS), as shown by the Kaplan-Meier curves in Figure 3.
Figure 3. Freedom from reintervention following CBA for all pulmonary artery segments in patients with TOF/PA/MAPCAs, genetic syndromes associated with PAS, and those without either diagnosis.
Multivariable logistic regression analysis confirmed that not having TOF/PA/MAPCAs and genetic syndromes increased the odds of a successful CBA by 70% (OR 0.30, CI 0.11-0.79, p = 0.01) and 91% (OR 0.09, CI 0.02-0.56, p = 0.01), respectively. Moreover, each increase in the maximum cutting balloon-to-MLD ratio by 0.5 improved the odds of success by a factor of 2.37 (CI 1.7-3.3, p = <0.0001).
This study further establishes CBA as a successful therapy for PAS resistant to conventional angioplasty. It also highlights two specific patient populations that remain difficult to manage. In TOF/PA/MAPCAs, PA stenoses may be very distal, long-segment lesions, at bifurcation points, or due to scarring at sites of surgical interventions. These patients may thus warrant earlier, more frequent and more aggressive catheterization. In Williams, Alagille and ATS, the abnormal arterial wall structure may prevent therapeutic tears required for a successful dilatation, and these patients may benefit more from surgical intervention instead.