Outcome of ductus arteriosus stenting including vertical tubular and convoluted tortuous ducts with emphasis on technical considerations

Abstract

Background: Ductal stenting is the preferred method of securing adequate pulmonary blood flow in patients with duct-dependent pulmonary circulation. The main limitation in most centers is the difficult vertical tubular or convoluted ducts that represent real challenges to interventional pediatric cardiologists. We present our experience in patent ductus arteriosus (PDA) stenting with some technical tips to overcome difficulties, especially in stenting tortuous or long tubular ducts. This study was conducted on all patients with cyanotic congenital heart disease who underwent PDA stenting between January 2011 and December 2018.

Results: We attempted to stent the PDA in 43 patients, with a success rate of 93% (40 patients) and only one procedural mortality. There was also one stent migration that needed to be treated with urgent surgery. Three-fourths of the patients had difficult ductal morphology and origin. One stent was used to cover the PDA in 27 patients (62.8%), two stents were used in 13 (30.2%), and three stents were used in 2 patients (4.6%). In-stent stenosis rate was 12.5% (5 patients) and the development of progressive left pulmonary artery stenosis was seen in two patients (5%). Pulmonary artery growth was adequate in all patients.

Conclusions: PDA stenting is an effective method of palliation for patients with duct-dependent pulmonary circulation. It has low morbidity and mortality rates. Stenting difficult ducts have become more feasible with evolving materials and techniques.

Keywords: Duct-dependent pulmonary; Patent ductus arteriosus; Single ventricle palliation; Stenting.

Fig. 1

Stenting a long tubular patent ductus arteriosus (PDA) from the subclavian artery. Upper panel images A–D show one stent used to cover the PDA. Lower panel images E–H show the use of 2 stents

Fig. 2

Stenting of double patent ductus arteriosus (PDA) in a patient with tetralogy of Fallot/pulmonary atresia and disconnected pulmonary arteries. The right pulmonary artery is supplied by a PDA from the subclavian artery that was stented with 2 stents (upper panel images, A–C). The left pulmonary artery is supplied by a PDA from the proximal descending aorta that was stented with one stent (lower panel images, D–F)

Fig. 3

In-stent stenosis. This is a patient with tricuspid atresia/pulmonary atresia and double patent ductus arteriosus (PDA) (A), both stented due to severe confluence stenosis (B), presented a few months later with desaturation and in-stent stenosis (C). Re-stenting with 2 more stents (D, E) was done successfully (F)

Fig. 4

Left pulmonary artery (LPA) stenosis and growth of pulmonary arteries associated with ductal stenting. A The vertical duct from the undersurface of the aortic arch, B The regular conical duct from the proximal descending aorta. C, D Pre-existing LPA stenosis. On routine follow-up angiography, there was a development of stent stenosis and LPA stenosis (E, F). Follow-up angiography images show adequate growth of pulmonary arteries despite right pulmonary artery jailing (G, H)

Fig. 5

Stenting a convoluted duct. The upper panel images (A–C) show the tortuous duct with the wire taking the same complete circle of the duct. The wire was manipulated to straighten the duct (D). Two stents were used to cover the whole length of the duct (E–F)

Fig. 6

Stenting a tortuous duct. (A) Angiography showing a tortuous duct. The wire was pushed to the pulmonary artery stump then reflected to one of the pulmonary branches (B) to straighten the duct and stent it safely (C–D)