Thoracoscopic Management of Patent Ductus Arteriosus and Vascular Rings in Infants and Children

Long-term Outcomes Following Thoracoscopic Division of Vascular Rings

OBJECTIVES

We evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center.

METHODS

All pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007-12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews.

RESULTS

60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time.

CONCLUSION

Division of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings.

LEVEL OF EVIDENCE

Level IV.

Transesophageal echocardiography-guided percutaneous patent ductus arteriosus closure without fluoroscopy

OBJECTIVES

A retrospective study was performed to summarize the experience of transcatheter closure of patent ductus arteriosus (PDA) through the right femoral vein under the guidance of transesophageal echocardiography (TEE).

METHODS

From January 2019 to September 2021, 75 children who underwent PDA closure through the right femoral vein under the guidance of TEE were included. The guide wire and delivery sheath were inserted through the ductus arteriosus into the descending aorta via the right femoral vein, and the occluder was subsequently deployed. After discharge, all patients were required for outpatient follow-ups at 1, 3, 6 and 12 months.

RESULTS

In this group, patients were older than 10 months of age and body weight greater than 8 kg. Among 75 cases with PDA, 63 were tubular type and 12 were conical type. The mean operative time was 40.2 ± 7.3 min. The size of PDA occluder ranged from 4-6 to 12-14 mm. The mean hospital stay was 5.5 ± 0.5 days. One month after discharge, there were 4 cases with a mild residual shunt. Eventually, the residual shunt was not observed during 3, 6, and 12 months of follow-up.

CONCLUSIONS

PDA closure under the guidance of TEE can be performed through the right femoral vein successfully and effectively. This procedure has no contrast agent usage, radiation exposure, or open incisions.

Application of robot-assisted endoscopic technique in the treatment of patent ductus arteriosus in 106 children

The objective is to evaluate and apply the robot-assisted endoscopic surgical technique for treatment of patent ductus arteriosus (PDA) in children. Clinical data of 106 children with PDA who underwent robot-assisted endoscopic operation were retrospectively analyzed from August, 2020 to March, 2022. Demographic and preoperative data were collected, including the patient's age, weight, diameter of the ductus arteriosus, operation time, length of postoperative hospital stay, postoperative complications and hospitalization cost. The age ranged from 6 months to 12 years with median age of 2.5 years. In addition, the weight ranged from 6.6 kg (kg) to 51.6 kg with median weight of 12.5 kg. Patients who received transcatheter PDA closure were also enrolled during the same period. Clinical features and perioperative data were compared between the two groups. All the 106 cases underwent robotically assisted surgery for PDA ligation. No one was converted to thoracotomy. The length of operation time was 15-84 min, with an average of 39.4 min. There was no obvious bleeding during the operation. The length of postoperative hospital stays were 1-3 days, with an average of 1.1 ± 0.2 days, which was significantly shorter than that of patients underwent transcatheter approach PDA closure (2.2 ± 0.2 days) (p < 0.05). The average hospitalization costs were US$ 8180 in the 106 patients, which were more expensive than that of ones who received transcatheter procedure (US$ 5076 ± 406) (p < 0.05). Only one case was found to have residual ductus shunt during early postoperative follow-up. One case was found with recurrent laryngeal nerve injury. The two cases recovered after 3 months of follow-up. The median duration of follow-up was 12 (1-20) months. No other short-term complications occurred during the follow-up period. Robotic surgical technique for PDA ligation in children is a safe, effective and reliable surgical method with less trauma, faster recovery and fewer surgical risks. This approach should be considered as an option in children patients requiring PDA ligation.

Thoracoscopy Versus Open Surgery for Persistent Ductus Arteriosus and Vascular Ring Anomaly in Neonates and Infants

BACKGROUND

The aim of our study was to report our experience in thoracoscopy in infants and neonates for vascular surgical conditions in neonates and infants and to compare our results to open surgery regarding the short-term outcome.

PATIENTS AND METHODS

We retrospectively reviewed all the patients operated in a single institution from 1997 to 2016 for persistent ductus arteriosus (PDA) and vascular ring (VR) anomalies. We compared our thoracoscopic series to a historical control group operated by open surgery. Data collection from charts and office notes included age and weight at surgery, cardiac ultrasound data for PDA, preoperative clinical symptoms for VR, type of surgery, operating time, analgesic treatment requirements, ventilation status during postoperative course, and early complications.

RESULTS

The thoracoscopic group included 13 PDA (median age and weight at surgery: 34 days and 1800 g) and 11 VR (median age and weight at surgery: 8 months and 7000 g). The thoracoscopic group did not differ in preoperative symptoms and work-up, operating time, ventilation status, length of hospital-stay, and postoperative complications with the group operated on by thoracotomy, for either PDA or VR.

CONCLUSION

Our short-term results in thoracoscopic PDA closure and VR anomalies surgery in neonates and infants are comparable to open surgery. Thoracoscopy seems to provide less pain especially for neonates and premature babies and allows to decrease the risk for postoperative chest wall deformities. Long-term outcome is mandatory to confirm these preliminary results.

Thoracoscopic division of vascular rings

BACKGROUND/PURPOSE

Vascular rings are traditionally treated via an open thoracotomy. In recent years the use of thoracoscopy has increased. Herein we report our experience with thoracoscopic division of vascular rings in pediatric patients.

METHODS

We reviewed all patients who underwent thoracoscopic or open division of a vascular ring at our institution between 2007 and 2015. We analyzed patient demographics, presenting symptoms, diagnostic imaging modality, ring anatomy, operative details, complications, and symptom resolution.

RESULTS

Thirty-one patients underwent thoracoscopic division of a vascular ring while sixteen had open operations. Median age was 24months in the thoracoscopic group and 13months in the open group. Operative time averaged 74min (thoracoscopic) and 95min (open). There were no mortalities at 30days. There was complete symptom resolution in 71% of thoracoscopic patients and 63% of open. Patients in the thoracoscopic group had decreased ICU admissions (10% vs. 94%), chest tube use (62% vs. 100%), chylothorax (6% vs. 38%) and overall length of stay (1.7days vs. 5days).

CONCLUSIONS

Thoracoscopic division of vascular rings in pediatric patients is a feasible alternative to open division and is associated with comparable rates of symptom resolution and decreased length of hospital stay and chylothorax.

LEVEL OF EVIDENCE

III.