Patent Ductus Arteriosus Stenting for All Ductal-Dependent Cyanotic Infants: Waning Use of Blalock-Taussig Shunts.
Ratnayaka K, Nageotte SJ, Moore JW, Guyon PW, Bhandari K, Weber RL, Lee JW, You H, Griffin DA, Rao RP, Nigro JJ, El-Said HG.
Circ Cardiovasc Interv. 2021 Mar;14(3):e009520. doi: 10.1161/CIRCINTERVENTIONS.120.009520. Epub 2021 Mar 9.
Take Home Points:
- PDA stenting in all neonates with ductal dependent pulmonary blood flow is feasible and results in good outcomes.
- Providers with less experience should consider gaining experience with stenting lower risk PDAs and then progress to higher risk PDA phenotypes.
- High risk characteristics may include: PDA tortuosity, small pulmonary artery size, at risk for PA discontinuity, or concern for PDA stent bronchus compression.
Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch:
Stenting of the patent ductus arteriosus (PDA) in patients with ductal dependent pulmonary blood flow (DDPBF) has shown to be non-inferior (and likely superior) to traditional palliation with a surgical modified Blalock-Taussig shunt (BTS). Most reports to date have reported on selective experience with PDA stenting (i.e. excluding patients felt to be at higher risk due to certain factors – PDA tortuosity, small pulmonary artery size, at risk for PA discontinuity, or concern for PDA stent bronchus compression, see Figure below). The authors report on a single center experience transitioning from selective PDA stenting to attempting PDA stenting in all patients with DDPBF.
The study compared 2 distinct periods: selective PDA stenting (Era 1, 2013-2017) and stenting all patients with DDPBF (2018-2020). A total of 88 patients were included for analysis (Era 1 = 66, 41 BTS and 25 PDA stent; Era 2 = 22 PDA stent, no BTS). The patients in the 2 eras were comparable. There was no difference in mortality (or other secondary outcomes measures) between treatment eras or between BTS and PDA stenting. Complication rates were similar between treatment eras and palliation approaches. Post-procedure length of stay was shorted in Era 2 (v Era 1). PDA stent patients had short post-procedure length of stay and more symmetric branch PAs at subsequent surgery.
The authors conclude that PDA stenting for all neonates with DDPBF is safe and effective and may have lower morbidity than selective PDA stenting. As more centers undertake PDA stenting as an alternative to palliation with surgical BTS it is important to understand what the best approach to introduce this procedure is. Centers new to PDA stenting may initially refer patients felt to be at highest risk for PDA stenting directly for surgical BTS. Experienced providers have demonstrated that even these high-risk patients can successfully undergo PDA stent implantation with outcomes that are equivalent to lower risk subtypes. Ratnayaka et al, very nicely describe a programmatic shift from performing selective PDA stenting to stenting PDAs in all patients with DDPBF with excellent overall outcomes. However, the excellent outcomes demonstrated in this report may be the result of earlier experience with lower-risk PDA stenting patients and less experienced providers should still be cautious when considering high-risk PDA phenotypes.
Preintervention, procedural, and postintervention angiograms of transaxillary PDA stenting for ductal dependent pulmonary blood flow (DDPBF) are shown. A patient with severe PDA tortuosity (type 3, multiple complex turns in ductus) is shown in A to C. A patient with small pulmonary arteries (also tortuosity index 3) is shown in D to F. A patient at risk for pulmonary artery discontinuity (3D reconstruction shows at risk left pulmonary artery [LPA]) because of ductal tissue is shown in G, H, and I. G, Posterior view demonstrating the LPA in purple and PDA and right pulmonary artery in beige. The arrow shows the origin of the LPA. Tortuous PDAs have been intentionally straightened in all 3 cases by a stiff guidewire (Ironman, Abbott, Santa Clara, CA).