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. 2014 Jun;25(6):889-94.
doi: 10.1016/j.jvir.2014.02.009. Epub 2014 Apr 1.

Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops

Sarah B White  1 , Sean M Tutton  2 , William S Rilling  2 , Randall S Kuhlmann  3 , Erika L Peterson  3 , Thomas R Wigton  4 , Mary B Ames  5
Affiliations

Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops

Sarah B White et al. J Vasc Interv Radiol. 2014 Jun.

Abstract

Purpose: To describe a transabdominal, transuterine Seldinger-based percutaneous approach to create a shunt for treatment of fetal thoracic abnormalities.

Materials and methods: Five fetuses presented with nonimmune fetal hydrops secondary to fetal thoracic abnormalities causing severe mass effect. Under direct ultrasound guidance, an 18-gauge needle was used to access the malformation. Through a peel-away sheath, a customized pediatric transplant 4.5-F double J ureteral stent was advanced; the leading loop was placed in the fetal thorax, and the trailing end was left outside the fetal thorax within the amniotic cavity.

Results: Seven thoracoamniotic shunts were successfully placed in five fetuses; one shunt was immediately replaced because of displacement during the procedure, and another shunt was not functioning at follow-up requiring insertion of a second shunt. All fetuses had successful decompression of the thoracic malformation, allowing lung reexpansion and resolution of hydrops. Three of five mothers had meaningful (> 7 d) prolongation of their pregnancies. All pregnancies were maintained to > 30 weeks (range, 30 weeks 1 d-37 weeks 2 d). There were no maternal complications.

Conclusions: A Seldinger-based percutaneous approach to draining fetal thoracic abnormalities is feasible and can allow for prolongation of pregnancy and antenatal lung development and ultimately result in fetal survival.

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Figures

Figure 1
Figure 1. Fetal hydrops
Transverse view of the fetal abdomen obtained as part of a fetal ultrasound. There is a large volume of ascites (black arrow) and skin thickening (calipers) which is consistent with non-immune fetal hydrops.
Figure 2
Figure 2. Thoracoamniotic shunt creation
Fetal ultrasound showing a sagittal oblique view of the fetal thorax. There is a large echogenic left chylous pleural effusion (black arrow). Under direct ultrasound guidance, an 18 G Inrad needle (arrowhead) was percutaneously advanced via a trans-abdominal, trans-uterine approach into the chylothorax. (fetal lung – white arrow, uterus – white arrowhead, amniotic fluid – dashed white arrow)
Figure 3
Figure 3. Thoracoamniotic shunt creation
Transverse view of the fetal thorax demonstrating a guide wire (white arrow) coiled in the fetal pleural effusion (dashed white arrow).
Figure 4
Figure 4. Thoracoamniotic shunt in situ with flow jet
Coronal oblique view of the fetal thorax status post fetal shunt placement. The trailing portion of the shunt is seen within the amniotic cavity (white arrow). Color Doppler images demonstrate a flow jet (white arrow) indicating flow through the shunt into the amniotic fluid (dashed white arrow).
Figure 5
Figure 5. Thoracoamniotic shunt in situ in-utero and postpartum
Transverse view of the fetal thorax with shunt (white arrow) in place and return of the mediastinum to midline. Immediate postpartum photograph demonstrating the in situ thoracoamniotic shunt (black arrow).
See this image and copyright information in PMC

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