The successful use of alternative routes of vascular access for performing pediatric interventional cardiac catheterization

Systematic approach to obtain axillary arterial access for pediatric heart catheterizations

Background

Axillary arterial access (AAA) in pediatric heart catheterizations is undervalued.

Methods

We retrospectively reviewed children with congenital heart diseases (CHDs) who received trans-axillary arterial catheterizations between January 2019 and February 2023. We aimed ultrasound-guided punctures in the proximal two-thirds of axillary arteries with diameters ≥2 mm to insert 7 cm/4 Fr short introducers. We administrated intra-arterial verapamil (1.25 mg) and heparin (100 UI/kg). We infiltrated per-operatively 2% lignocaine (10 mg) for arterial spasms, long sheaths use (≥5 Fr), and ≥60 min procedures in <3 kg patients.

Results

We identified 30 patients (66.7% males) with a median age of 1.1 months (IQR, 0.3-5.4), and a median weight of 3.1 kg (IQR, 2.7-3.7). 5/30 patients had six redo interventions after a median of 3.9 months (IQR, 1.7-5.1). Overall, 27/36 procedures were interventional, including 6 aortic valvuloplasties, 6 balloon angioplasties, and 15 stenting procedures. The median arterial axillary angiographic diameter was 2.6 mm (IQR, 2.4-3). Access was right-sided in 23/36 (63.9%) procedures and obtained using 21G/2.5 cm bevel needles in 25/36 (69.4%) procedures. No hemodynamical change occurred after introducing spasmolytic drugs. The median fluoroscopy time was 26.1 min (IQR, 19.2-34.8). There were two self-resolving arterial dissections, one sub-occlusive arterial thrombosis (resolved with 6 weeks of enoxaparin), and one occlusive arterial thrombosis (resolved with alteplase thrombolysis and 6 weeks of enoxaparin). Median follow-up was 11.7 months (IQR, 8-17.5). Four patients with complex univentricular hearts died from non-procedural causes at a median of 40 days (IQR, 31-161) postoperative.

Conclusion

Systematic approach for AAA is the key to success and unlocks the many potentials of trans-axillary pediatric cardiology interventions.

Establishing Carotid Seldinger as Routine Access in Infants; Planning, Performance, and Follow-Up Protocols

Percutaneous carotid access (PCA) in infants has been reported in small multicenter cohorts, case reports and wider studies over the last 20 years. Compare outcomes after implementation of a systematic approach to PCA in a single center including an imaging follow-up protocol. Retrospective case-control study of PCA at Children's Hospital Colorado was performed from January 2013 to December 2022. Seventy-four patients underwent 82 PCAs for cardiac catheterization. The median age (range) was 14 days (1-359), and weight was 3.25-kg (1.9-7.9). Median sheath size was 4-Fr (3.3-6). Seventy-seven interventions performed included PDA stenting, aortic valvoplasty, BTT shunt stenting, and coarctation stenting. Vascular access was performed using a modified 21 g butterfly needle. A protocolized approach was implemented in 2020 reversing the patient head-to-toe orientation on the catheterization table, maintaining intubation and sedation for 4-h during recovery and routine use of a specific vascular ultrasound protocol. Following these changes, time to access significantly improved with no major complications. Before 2020, two access related complications occurred. One requiring surgical vascular repair and one occlusive thrombus. A significant increase in sheath time in post-era was associated with increased case complexity. Longer sheath times were not associated with increased risk of vessel injury or thrombus. No neurological insults were reported. Our experience confirms that PCA is safe and achievable with preserved vessel patency regardless of patient weight or sheath size. A protocolized planning, recovery, and follow-up regimen is recommended to establish safe practice and identify and treat complications as necessary.

Carotid artery cut-down technique for ductus arteriosus stenting

Background

This study aims to evaluate early and mid-term outcomes of ductal stenting via carotid artery surgical cut-down technique in neonates.

Methods

Between January 2015 and January 2022, a total of 17 neonates (12 males, 5 females; median age: 14 days, range, 5 to 34 days) who underwent carotid artery surgical cut-down technique for ductal stenting were retrospectively analyzed. Diagnoses of the patients, demographics, procedural success/failure, access-related complications, and neuroimaging findings were recorded.

Results

The primary indication for ductal stenting was pulmonary atresia in all patients. All patients who underwent carotid cut-down had vertical anatomy, with or without tortuous ductal anatomy, and they were not suitable for the femoral approach. The median body weight was 3 (range, 2 to 3.4) kg. Fifteen of the 17 interventions (88.2%) were successful. Two patients whose stenting failed underwent a systemic-to-pulmonary shunt operation. The early in-hospital mortality rate was 17.6% (n=3). No neurological or accessrelated complications were observed in any of the patients.

Conclusion

Stenting the ductus arteriosus with challenging anatomy is feasible and safe with carotid artery cut-down, particularly in small neonates. Based on our study findings, this technique may offer an effective and less invasive alternative to the systemic-to-pulmonary shunt operation.

Catheter Intervention for Flow Regulatory Clips on Palliative Shunts and Conduits in Patients with Congenital Heart Disease

Catheter intervention (CI) for a Blalock-Taussig shunt (BTS) or a ventricle-to-pulmonary artery conduit (VPC) is often required after a palliative surgery for congenital heart disease. Flow regulatory clips help improve interstage mortality; their use necessitates CIs to prevent cyanosis. To study the CI outcomes in patients who underwent palliative surgery with either BTSs or VPCs with flow regulatory clips. This single-center retrospective study evaluated demographic characteristics and interventional outcomes of 49 consecutive pediatric patients who required CI for BTS (BTS group) or VPC (VPC group) between January 2008 and September 2018. Overall, 34 and 18 procedures were performed in the BTS and VPC groups, respectively. Moreover, 19/32 (59.3%) and 12/17 (70.1%) patients from the BTS and VPC groups had flow regulatory clips, respectively. All clips were unclipped successfully; one patient in each group underwent staged unclipping. A higher proportion of "clipped patients" underwent CI due to desaturation [clipped vs. non-clipped: BTS, 10/20 (50.0%) vs. 3/14 (21.4%), p = 0.092; VPC, 9/13 (69.2%) vs. 1/5 (20.0%), p = 0.060]. Most clipped patients successfully progressed to the next stage [BTS, 19/20 (95.0%); VPC, 12/13 (92.3%)]. Severe adverse events (SAEs) were more frequent in the VPC group than in the BTS group [3/13 (23.1%) vs. 0/20 (0%), p = 0.024]. Two patients developed an atrioventricular block (requiring an atropine infusion), while one died due to pulmonary overcirculation. While the indication of CI was cyanosis for a higher proportion of clipped patients, all clips were unclipped successfully. The incidence of CI-related SAEs was higher in the VPC group than in the BTS group.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence

Background

Patients with cyanotic complex congenital heart defects (CHDs) commonly undergo palliation with interposition of systemic-to-pulmonary shunts (SPSs). These palliative shunts are rarely found in adults with CHDs and can be complicated with progressive obstruction or total occlusion during follow-up. The best treatment option for shunt re-permeabilization is challenging and case-oriented because most patients are high risk candidates for redo surgeries. We aimed to review the current evidence on percutaneous stent implantation to treat failed SPSs.

Methods

We performed a comprehensive literature review on percutaneous stent implantation to treat failed and occluded SPSs. We also reported the case of a 33-year-old man with cyanotic CHD and a occluded central aorto-pulmonary shunt, who was successfully treated with percutaneous balloon dilatation and subsequently stent implantation at our institution.

Result

We identified and included 31 articles reporting on 150 patients and 165 stent implantations in failed SPSs. The age of patients at the time of stent implantation ranged from 6 days to 47 years. The time between the surgical shunt creation and transcatheter intervention ranged from 1 day to 17 years. Overall, 161/165 (97.5%) stent implantations were successful. The most common clinical presentation was cyanosis and decreased atrial oxygen saturations and the indication for stent implantation was shunt obstruction and stenosis.

Conclusion

This review highlights the benefits of endovascular stenting to permeabilize failed SPSs in children and adults with complex CHD who are classified as poor candidates for re-surgical repair.

Percutaneous Common Carotid Artery Access for Cardiac Interventions in Infants Does Not Acutely Change Cerebral Perfusion

Pediatric cardiac interventions via percutaneous common carotid artery (CCA) access have been shown to be safe and effective. However, the impact of placement of a sheath in the carotid artery for interventions on cerebral perfusion is unknown. In this study we used cerebral near-infrared spectroscopy (NIRS) to analyze the effects of percutaneous CCA access for cardiac interventions on cerebral perfusion. This study is a retrospective chart review carried out at a tertiary care center on all pediatric patients who underwent percutaneous cardiac catheterization via carotid artery access from January 2010 to January 2020. All patients who had ipsilateral NIRS recorded on the side of carotid artery access were included. Patients with only partial or no ipsilateral NIRS data were excluded. The primary outcome measure was the change in NIRS upon CCA access; the mean NIRS for 15 min before obtaining access was compared to the mean NIRS during the procedure and to the mean NIRS 15 min after removal of the CCA sheath. We hypothesized that there would be a significant drop in NIRS values on the side of CCA access. There were 48 catheterizations in the study period where percutaneous CCA was accessed. Of those, 21 catheterizations had complete data and were included in the study. 13 (62%) were of males. The median age was 23 days (IQR 7-79). The indications for CCA access were patent ductus arteriosus stent implantation (n = 13; 62%), aortic valvuloplasty (n = 5; 24%), balloon angioplasty of coarctation of aorta (n = 2; 10%), and renal artery angioplasty (n = 1; 4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3 kg (IQR 2.8-2.9). The most common sheath size used was 4F, in 16 patients (72%). The mean NIRS prior to the procedure was 67 ± 15%, during the procedure was 68 ± 20%, and after removal of sheath was 68 ± 21%. Paired t test of cerebral NIRS before, during, and after the procedure showed no significant change with CCA access (P = 0.08). No patient in the series had a documented neurologic deficit following the procedure. Percutaneous CCA access was not associated with a decrease in NIRS on the side of the access during the procedure, suggesting there was no significant acute change in cerebral perfusion with CCA access.

Transradial access for pediatric teenage neurointervention: A single-center case series

Transradial access is widely used in cardiological adult interventions and less in pediatrics. In recent years, this access has become more popular in the neuroradiological community in adult patients since it has fewer complications and is more comfortable for the patient after the procedure. We present a single-center case series of 52 transradial access neurointerventions (43 angiographies and 9 therapeutic procedures) in pediatric patients, with a failure of 4 cases (7.7%) in which we could not puncture the artery, crossing over to transfemoral access. Since in five cases we did angiography followed by therapeutic intervention, thus doing only one puncture access for both procedures, then our access failure rate was 10.6%. The 34 successful transradial access solely angiographies had a median radiation exposure of 887 mGy (interquartile range 628-1352), median fluoroscopy time of 9.5 min (interquartile range 7.5-15.3), and median procedure time of 28 min (interquartile range 24-33 min) Therapeutic procedure diagnosis were: one ruptured saccular aneurysm, two juvenile nasopharyngeal angiofibromas, and five arteriovenous malformations. The transradial access neurointerventions for pediatric population older than 11 years is safe and feasible, having previous experience in adults. Younger population should be considered on a case-to-case basis, depending on ultrasound measurement of the arterial diameter and the materials available.

Carotid access for percutaneous coronary intervention

Transcarotid percutaneous coronary intervention is feasible and safe and can be considered as an ultimate alternative in cases where conventional peripheral vascular access is unavailable.

Hybrid Procedures. Opening Doors for Surgeon and Cardiologist Close Collaboration

Background: Collaboration between cardiac surgeons and cardiologists can offer interventions that each specialist may not be able to offer on their own. This type of collaboration has been demonstrated with the hybrid Stage I in patients with hypoplastic heart syndrome. Since that time, a hybrid approach to cardiac interventions has been expanded to an incredible variety of potential indications. Methods: Seventy-one patients were scheduled for a hybrid procedure along 8 years. This was defined as close collaboration between surgeon and cardiologist working together in the same room, either cath-lab (27 patients) or theater (44 patients). Results: Six groups were arbitrarily defined. A: vascular cut-down in the cath-lab (27 neonates); B: bilateral banding (plus ductal stent) in hypoplastic left heart syndrome or alike (15 children); C: perventricular closure of muscular ventricular septal defect (10 cases); D: balloon/stenting of pulmonary branches along with major surgical procedure (12 kids); E: surgical implantation of Melody valve (six patients) and others (F, one case). Two complications were recorded: left ventricular free wall puncture and previous conduit tearing. Both drawbacks were successfully sort out under cardiopulmonary by-pass. Conclusion: Surgeon and cardiologist partnership can succeed where their isolated endeavors are not enough. Hybrid procedures keep on spreading, overcoming initial expectations. As a bridge to biventricular repair or transplant, bilateral banding plus ductal stent sounds interesting. Novel indications can be classified into different groups. Hybrid procedures are not complication-free.

Case Report: Trans-axillary Artery Access for Rescue Stent Implantation in an Infant With Retrograde Non-passable Aortic Coarctation

Primary surgical repair remains the traditional treatment for patients with critical duct-dependent coarctation of the aorta (CoA). Initial surgical repair might not be possible or associated with higher risks if additional comorbidities arise in small infants and neonates. Balloon angioplasty (BA) has been described as a rescue strategy for these children. We describe the feasibility of a palliative BA and rescue stent implantation via an alternative antegrade right-axillary artery approach in an initially inoperable infant with pneumonia and respiratory failure and severe CoA, where the stenosis was not passable by traditional retrograde femoral access. This case adds new aspects to the therapy of critical CoA: Stent implantation provides a bridge to surgery in critically ill infants and does not preclude successful surgical repair. Further, if the classic retrograde approach is not possible, the right axillary artery access should be considered as an alternative to pass the stenosis.

Catheter strategy to ease the procedure and reduce radiation exposure when requiring neck access

OBJECTIVES

To assess the potential occupational radiation reduction and technical feasibility in patients rotated 180° (upside-down) when requiring neck access for transcervical or trans-subclavian catheterisation.

METHODS

Upside-down positioning is defined as rotating patients in supine position by 180°, so that the feet come to rest where the head would otherwise be. We retrospectively evaluated all these procedures performed between March 2016 and May 2019. Furthermore, two different phantoms (paediatric and adult) were used prospectively to quantify the occupational dose between conventional or upside-down positioning. In this context, ambient dose equivalents were measured using real-time dosimeters. Three different projection angles were applied.

RESULTS

44 patients with median age and body weight of 1.0 year (range 0-56) and 9.5 kg (range 1.3-74.3) underwent 63 procedures positioned upside-down. This position proved advantageous for practical reasons, since the length of the examination table could be optimally used. Additionally, it resulted in a significantly lower overall ambient dose equivalent for the primary operator (PO) of 94.8% (mean: 2569±807 vs 135±23 nSv; p<0.01) in the adult, and of 65.5% (mean: 351±104 vs 121±56 nSv; p<0.01) in the paediatric phantom, respectively.

CONCLUSION

Upside-down positioning facilitates handling in a straightforward manner when access from the neck is required. Moreover, it significantly reduces local radiation exposure for the PO in the paediatric and, most impressively, in the adult phantom.

Use of percutaneous carotid artery access for performing pediatric cardiac interventions: Single-center study

Background:

Carotid artery (CA) access allows a more straight route for many left heart lesions. This has previously been achieved via a surgical cut-down approach in certain pediatric cardiac interventions. However, there are little data considering CA access in pediatric cases, percutaneously.

Aim:

We hypothesized that there would be notable improvements in efficiency as well as overall success when using the CA for access in selected cases.

Methods:

Between November 2016 and January 2019, records of patients undergoing attempted percutaneous CA access under ultrasound guidance for cardiac catheterization were reviewed.

Results:

Thirty patients underwent 36 catheterizations; median age 17 days (range, 6 days–9 months) and median weight 3.2 kg (1.2–7.8). Procedures performed were stenting or stent redilatation of the patent ductus arteriosus in 23, stenting or angioplasty of modified Blalock–Taussig shunts in four, aortic valvuloplasty in three, angioplasty for coarctation of the aorta in four, renal angioplasty in one, and diagnostic catheterization in one case. The intended intervention was unsuccessful in two patients despite successful CA access. Follow-up imaging showed a normal carotid in 28 of 30 (94%), with mild luminal narrowing with normal Doppler velocities in two instances. No patient had clinically apparent neurological sequelae attributable to CA access.

Conclusions:

Our data indicate that CA access should be employed when dealing with a select group of infants requiring vertical approach for left-sided cardiac lesions. Percutaneous CA access, even in very small preterm infants, is safe and feasible with negligible vascular injury and no neurological adverse events.

Balloon angioplasty of aortic coarctation in critically ill newborns using axillary artery access

Balloon angioplasty may be performed as the first treatment of aortic coarctation to stabilize newborns too sick for immediate surgery. The issue of vascular access is the key to the successful treatment of critical newborns. In our study, we argue that the lesser-known axillary access route is the safest and most effective route of vascular access for balloon angioplasty in infants with aortic coarctation. To support this argument, we present the case of eight unstable newborns with complex heart diseases, who were successfully treated with percutaneous intervention through the axillary artery. This case series is followed by an analysis of the greater efficacy of this technique compared to the more conventional femoral and carotid routes. We conclude by acknowledging the substantial advantages of this lesser-known vascular access and advocate its more widespread clinical implementation in the treatment of critical newborns.

Accessing extracorporeal membrane oxygenation circuits to perform emergent interventional cardiac catheterisation

Cardiac catheterisation in patients on extracorporeal membrane oxygenation (ECMO) may reveal new information leading to modification of a therapeutic plan and correction of newly recognised or residual lesions. Complications associated with cardiac catheterisation during ECMO are not uncommon and often related to the access site. We report a straightforward technique for accessing the ECMO circuit to perform an emergent cardiac catheterisation in two patients with hypoplastic left heart syndrome decompensated after Norwood I, due to presumed systemic-to-pulmonary artery shunt obstruction.

Transhepatic Vascular Access for Implantation of a Watchman Left Atrial Appendage Closure Device

Conventional access through femoral veins may be limited due to tortuosity and venous occlusion secondary to venous thrombosis or congenital anomalies. Another alternative is subclavian veins, but the difficulty in catheter manipulation and stability makes it less favorable in comparison to the transhepatic access for the delivery of the Watchman device.

Stenting the complex patent ductus arteriosus in tetralogy of Fallot with pulmonary atresia: challenges and outcomes

Patent ductus arteriosus (PDA) stenting has gained acceptance for palliation in cyanotic congenital heart disease. The PDA in tetralogy of Fallot with pulmonary atresia (ToF-PA) arises, in the left aortic arch, from underneath the arch and connects to the proximal left pulmonary artery, often resulting in stenosis. The PDA is usually elongated and tortuous, making stent implantation challenging. Shorter duration of palliation, aggravation of branch pulmonary artery stenosis resulting in poor growth and difficulty at surgery makes ductal stenting controversial. Access via the carotid and axillary artery reduces complexity of the procedure and improves success, with recent data demonstrating good pulmonary artery growth. Advances in bioresorbable stents offer future promise and will likely resolve some controversies surrounding PDA stenting in ToF-PA.

Intervention on Surgical Systemic-to-Pulmonary Artery Shunts: Carotid Versus Femoral Access

OBJECTIVES

The purpose of this study was to compare results between the femoral arterial (FA) and carotid arterial (CA) approaches in catheter-based interventions on Blalock-Taussig shunts (BTS).

BACKGROUND

Transcatheter intervention on BTS is often performed in shunt-dependent, hypoxemic infants. The approach to BTS intervention likely has an impact on timeliness and overall success.

METHODS

The authors reviewed all cases of catheter intervention for BTS obstruction between 2012 and 2017 for their institution. They sought to compare procedural success rates and time, sheath time, time to arterial access, and time from access to stent implantation between FA and CA approaches.

RESULTS

There were 42 BTS interventions between 34 patients. BTS intervention was more successful from the CA approach (p = 0.035). Among the FA cohort, BTS intervention was unsuccessful in 8 cases (25%), 5 of which were converted to CA with subsequent success. The CA cohort had lower procedure time (62 min vs. 104 min; p = 0.01) and anesthesia time (119 min vs. 151 min; p = 0.01). Additionally, CA access was associated with shorter time to arterial access (4.0 min vs. 9.3 min; p < 0.01), time to placement of the guidewire through the BTS (6.5 min vs. 13 min; p < 0.01), and time from the final sheath to BTS stent implantation (9 min vs. 20 min; p < 0.01).

CONCLUSIONS

Operators should consider the route of access to the BTS deliberately. The authors' approach has been the carotid artery as an alternative access site-associated with greater procedural success, shorter procedural time, and shorter time to stent implantation.

Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization

Background—

Surgical cutdown for access to the common carotid artery provides a more direct route for certain pediatric cardiac interventions and avoids femoral artery injury in small infants. The safety of percutaneous carotid access (PCA) in children is unknown.

Methods and Results—

Retrospective review of PCA at Texas Children’s Hospital and Children’s Healthcare of Atlanta. From July 2006 to November 2014, 42 patients underwent 47 attempts at catheterization via PCA. Median (range) age was 20 days (0 days–2.9 years) and weight was 3.2 kg (1.1–12.2). Two patients had failed PCA with no sequelae. Of the 45 catheterizations with successful PCA and sheath placement, 44 interventions were performed, the most common being stenting or stent redilation of the ductus arteriosus, balloon aortic valvuloplasty, and stenting or angioplasty of Blalock–Taussig shunts. After sheath withdrawal, hemostasis was achieved with manual compression, with no need for surgical control of bleeding. Follow-up carotid imaging was performed in all. Acutely, 3 patients developed carotid thrombosis with resolution in 1 and mild residual narrowing in 2 after anticoagulation therapy. At follow-up, 40 of 42 patients (95%) had a normal carotid artery, with 2 instances of mild stenosis. There were no neurological sequelae attributable to PCA.

Conclusions—

PCA is safe even in small infants, and hemostasis can be achieved without surgical repair, with a carotid patency rate superior to published data after surgical cutdown. Surgical cutdown is not routinely required for pediatric cardiac catheterization via the carotid artery.

Balloon angioplasty and stent implantation performed through systemic-to-pulmonary artery shunts in infants and neonates

Branch pulmonary artery stenosis (BPAS) in the setting of systemic-pulmonary artery shunts (SPS) may result in significant sequelae. Limited information exists regarding the safety and efficacy of pulmonary artery balloon angioplasty and stent implantation via SPS in neonates and infants. This study aimed to examine the feasibility, safety, and efficacy of balloon angioplasty/stent implantation for BPAS performed via SPS in neonates and infants. A single-center retrospective analysis of all patients weighing 10 kg or less who underwent angioplasty for BPAS via SPS was performed. Systemic oxygen saturations and vessel diameter before, during, and after the procedure were compared. Between July 1996 and February 2008, 15 patients underwent 20 catheterizations for the treatment of 27 BPAS via SPS. The patients had a mean weight of 5.6 kg (range, 2.6-10 kg) and a mean age of 7.6 months (range, 7 days to 33 months). The SPS diameter ranged between 2 and 5 mm (median, 3.5 mm). Angioplasty was performed for all 27 lesions, and an additional stent was placed in 5 of these. The average lesion diameter increased from 2.3 ± 1.5 to 4.7 ± 1.7 mm (p < 0.05), and 25 (93 %) of the 27 lesions met the predetermined criteria for success. Systemic oxygen saturation increased from 73 ± 9.5 % to 82 ± 6.8 % immediately after intervention and was 83 ± 7.9 % at discharge (p < 0.05). There were no instances of shunt thrombosis. Two patients experienced transient hypotension during the procedure. No procedural deaths occurred. The study findings suggest that balloon angioplasty or stent implantation performed via SPS appears to be safe and effective treatment for BPAS in neonates and infants.

Percutaneous transhepatic access for catheter ablation of cardiac arrhythmias

AIMS

Femoral venous access may be limited in certain patients undergoing electrophysiology (EP) study and ablation. The purpose of this study is to review a series of patients undergoing percutaneous transhepatic access to allow for ablation of cardiac arrhythmias.

METHODS AND RESULTS

Six patients with a variety of cardiac arrhythmias and venous abnormalities underwent percutaneous transhepatic access. Under fluoroscopic and ultrasound guidance, a percutaneous needle was advanced into a hepatic vein and exchanged for a vascular sheath over a wire. Electrophysiology study and radiofrequency ablation was then performed. All tachycardias, including atrial tachycardia, atrial flutter, atrioventricular nodal tachycardia, and atrial fibrillation, were ablated. Procedural times ranged from 227 to 418 min. Fluoroscopy times ranged from 32 to 95 min. There were no complications. All six patients have been arrhythmia-free in follow-up (5-49 months, mean 23.1 months).

CONCLUSION

Percutaneous transhepatic access is safe and feasible in patients with limited venous access who are undergoing EP study and ablation for a range of cardiac arrhythmias.

Future horizons for catheter-based interventions in adult congenital and structural heart disease

In recent decades, there has been an exponential growth in both the number and range of catheter-based interventions for adult congenital and structural heart disease. In this article, we discuss the rationale for the ongoing development of minimally invasive multidisciplinary interventions; the required training elements necessary to achieve expertise in the field; the cardiac team needed to best perform these interventions; and the currently available and up and coming technologies for performing transcatheter valve therapies.

Carotid access for cardiac catheterization: revisiting the past for a complex intra-arterial approach

Historically, multiple arterial access sites have been used for cerebral, peripheral or coronary angiography prior to the widespread utilization of the safer transbrachial and, more recently, transfemoral or transradial approaches. Additionally, alternative sites for arterial access such as the carotid artery are often used in complex pediatric invasive procedures. We describe a case of a patient with severe peripheral arterial occlusive disease with active ischemia who required coronary angiography. In collaboration with cardiothoracic surgery, carotid cutdown was successfully performed in the cardiac catheterization laboratory to allow performance of diagnostic coronary angiography and intravascular ultrasound.

Bailout stenting for critical coarctation in premature/critical/complex/early recoarcted neonates

BACKGROUND

Surgical repair of critical coarctation can be problematic in premature, critical, complex, or early postoperative neonates.

OBJECTIVES

We aimed to review our experience with stent implantation to defer urgent surgery to an elective time.

METHODS

Fifteen neonates with severe aortic coarctation: five premature-hypotrophic (1,400-2,000 g), six critical and complex cardiac malformation, four early (1 day [0-2 days]; median [range]) after surgical coarctectomy or complex arch reconstruction. Bare coronary stents (diameter 4.0 [3.5-5.0] mm; length 10 [8-16] mm) were used. Stents were removed surgically depending on clinical needs.

RESULTS

Adequate aortic flow was obtained in 15 patients. The femoral artery was preserved in 13/15 patients. Two deaths occurred before stent removal and were nonprocedure related. In patients with simple stented coarctation, the stent was removed after 2.8 [0.2-5.0] months. In complex cardiac malformation, stents were finally removed 3.0 [0.2-78] months after implantation.

SURGICAL TECHNIQUE

simple coarctectomy end-to-end in eight, extensive arch patch reconstruction in four. One patient is awaiting stent removal. The final maximum systolic velocity (cw-Doppler) across the aortic arch was 1.7 [1.2-2.5] m/sec.

CONCLUSIONS

In premature/critical/complex neonates with severe coarctation, bailout stenting followed by early or late surgical coarctectomy appears a promising concept.