Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization

Stenting of the Patent Ductus Arteriosus

Since PDA stenting was first attempted in the early 1990s, significant technical advancements have improved outcomes and some centers have even transitioned to exclusive PDA stenting for all infants with duct-dependent pulmonary circulation. In addition to its use in infants with duct-dependent pulmonary circulation, PDA stenting has also been adapted as a percutaneous palliative option for suprasystemic pulmonary arterial hypertension and as a component of the hybrid procedure. In this article, the authors aim to review indications and outcomes for PDA stenting, describe the procedure, and discuss future directions.

Modified Theoretical Model Predicts Radial Support Capacity of Polymer Braided Stents

BACKGROUND AND OBJECTIVE

Self-expanding polymer braided stents are expected to replace metallic stents in the treatment of Peripheral Arterial Disease, which seriously endangers human health. To restore the patency of blocked peripheral arteries with different properties and functions, the radial supporting capacity of the stent should be considered corresponding to the vessel. A theoretical model can be established as an effective method to study the radial supporting capacity of the stent which can shorten the stent design cycle and realize the customization of the stent according to lesion site. However, the classical model developed by Jedwab and Clerc of radial force is only limited to metallic braided stents, and the predictions for polymer braided stents are deviated.

METHODS

In this paper, based on the limitation of the J&C model for polymer braided stents, a modified radial force model for polymer braided stents was proposed, which considered the friction between monofilaments and the torsion of the monofilaments. And the modified model was verified by radial force tests of polymer braided stents with different structures and monofilaments.

RESULTS

Compared with the J&C model, the proposed modified model has better predictability for the radial force of polymer braided stents that prepared with different braided structure and polymer monofilaments. The root mean squared error of modified model is 0.041±0.026, while that of the J&C model is 0.246±0.111.

CONCLUSIONS

For polymer braided stents, the friction between the polymer monofilaments and the torsion of the monofilaments during the radial compression cannot be ignored. The radial force prediction accuracy of the modified model considering these factors was significantly improved. This work provides a research basis on the theoretical model of polymer braided stents, and improves the feasibility of rapid personalized customization of polymer braided stents.

Point-of-Care-Ultrasound in Pediatrics: A Review and Update

Point-of-Care-Ultrasound (POCUS) has encountered a tremendous expansion in patient care. POCUS has taken a central role during invasive procedures. POCUS has expanded to most subspecialties from adult to pediatric and neonatal health care. POCUS in pediatrics has also become part of specific critical situations such as myocardial function assessment during cardiac arrest, extracorporeal membrane oxygenation deployment and neurological evaluation. In this review we will go over the most important historical aspects of POCUS. We will also review important aspects of POCUS in the intensive care unit, cardiologist evaluation and in the emergency department among others.

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.

Endovascular transmural access to carotid artery perivascular tissues: safety assessment of a novel technique

BACKGROUND

Recent advances in endovascular devices have allowed access and targeting of perivascular tissues of the peripheral circulation. The perivascular tissues of the cervical and cranial circulations have many important structures of clinical significance, yet the feasibility and safety of such an approach has not been demonstrated.

OBJECTIVE

To evaluate the safety of a novel endovascular transmural approach to target the perivascular tissues of the common carotid artery in swine.

METHODS

A micro-infusion device was positioned in the carotid arteries of three Yorkshire pigs (six carotid arteries in total), and each carotid artery was punctured 10 times in the same location to gain access to the perivascular tissues. Digital subtraction angiography was used to evaluate vessel injury or contrast extravasation. MRI and MR angiography were used to evaluate evidence of cerebral ischemia or vessel injury. Post-mortem tissue analysis was performed to assess the level of extravascular hematoma and intravascular dissection.

RESULTS

None of the tested carotid arteries showed evidence of vessel injury (dissection or perforation) or intravascular thrombosis. MRI performed after repeated puncture was negative for neck hematoma and brain ischemia. Post-mortem tissue analysis of the carotid arteries showed mild adventitial staining with blood, but without associated hematoma and without vessel dissection.

CONCLUSION

Repeated puncture of the carotid artery to gain access to the perivascular tissues using a novel endovascular transmural approach is safe in a swine model. This represents a novel approach to various tissues in close proximity to the cervical and cranial vasculature.

A rare complication after an interventional procedure using the common carotid: carotid pseudoaneurysm in an infant

The carotid artery is a valuable vascular access that can be used in patients who have undergone repetitive interventional and surgical procedures and premature babies. In the past, cut-down was used but nowadays, mostly the procedure is performed under ultrasonographic guidance. Complications such as bleeding, haematoma, and pseudoaneurysm may occur when the carotid artery is used as a vascular access for the procedures such as aortic balloon valvuloplasty, coarctation balloon angioplasty, or after interventional or surgical treatments to the carotid artery. Although pseudoaneurysm is very rare, prompt diagnosis and accurate treatment planning are life-saving. In this article, the diagnosis and treatment of pseudoaneurysm in the left common carotid after transcatheter coarctation balloon angioplasty in a 6-month-old infant will be presented.

Erratum: Stenting of the Patent Ductus Arteriosus: A Meta-analysis and Literature Review

[This corrects the article DOI: 10.1016/j.jscai.2022.100392.][This corrects the article DOI: 10.1016/j.jscai.2023.101051.].

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.

Stenting of the Patent Ductus Arteriosus: A Meta-analysis and Literature Review

Background

Patent ductus arteriosus (PDA) stent placement and systemic-pulmonary surgical shunt procedure can both be performed as palliation for infants with duct-dependent pulmonary circulation. The aim of this meta-analysis and literature review was to compare outcomes and study populations between the 2 methods as well as review the technical considerations and complications of PDA stenting.

Methods

A systematic search was conducted using the PubMed database and meta-analysis was performed. Risk ratio and mean difference were used to compare the reported outcomes of studies across patients receiving PDA stent and surgical shunt.

Results

In total, 1094 patients from 8 comparative observational studies were included. The PDA stent group had a lower mortality rate and a shorter hospital length of stay than the systemic-pulmonary surgical shunt group, although at the expense of increased reintervention rates. There were higher proportions of patients with single-ventricle physiology and single-source pulmonary blood flow in the surgical shunt group.

Conclusions

PDA stenting appears to be a noninferior or possibly superior method of palliation for duct-dependent pulmonary circulation compared with systemic-pulmonary surgical shunt, recognizing, however, that patients receiving surgical shunt more often had single-ventricle physiology or single-source pulmonary blood flow in this meta-analysis.

Stenting of critical aortic coarctation in neonates between 600 and 1,350 g. Using a transfemoral artery approach. A single center experience

Background

Stenting of aortic coarctation (CoA) in newborns with a very low bodyweight remains rare and challenging. In this study we aim to highlight on two points: first the feasibility of CoA stenting in such babies and second the importance of using echocardiogram for guiding the intervention without the need for contrast agent.

Methods

Between 2020 and 2022 three preterm babies with very low (VLWB) and extremely low weight (ELWB) underwent CoA-stenting in our center. The weight of the patients at time of intervention was 1,350, 1,200, and 600 g, respectively. The femoral artery was chosen in all patients as vascular access. Transthoracic echocardiography, sonography of the femoral arteries and head ultrasound were applied for follow up.

Results

All three interventions were successfully done, with no complications. Coronary stents were implanted. In one Patient (1,350 g) the stent was inserted without sheath. In two patients with renal failure, the stenting was performed under echocardiography-guidance without contrast agent. The follow up showed a preserved function of the left ventricle in all patients. No relevant gradient was reported and no stent re-intervention was required. Sonographic follow up showed a patent femoral artery in all patients. Two patients were operated 73 and 110 days after stenting, and the stents were successfully removed. In the third patient the intervention was performed 130 days ago and he is waiting for the operation.

Conclusion

CoA-stenting in VLWB and ELWB is feasible and can bridge them to the next surgery without complications. Echocardiography-guided CoA-stenting in VLWB is a considerate option especially in patients with renal failure. Accessing the femoral artery by experienced doctors, using local anesthesia before the puncture and before removing the sheath might help to protect the vessel from stenosis or occlusion.

Hybrid stenting of the arterial duct with carotid cutdown and flip technique: immediate and early results

Stenting of the arterial duct (PDA) has become a standard palliation for ductal-dependent pulmonary circulation. Carotid arterial access provides a direct route for stenting vertical ducts. We evaluated our early results of hybrid ductal stenting via surgical carotid cutdown.

METHODS AND RESULTS

In this retrospective single centre cohort study, hybrid PDA stenting was attempted in 11 patients with "flip technique", between January 2020 and February 2021, and was successful in 10. Median age was 29 days (interquartile range 17.5-87) and mean weight 3.37 ± 1.23 kg. Mean fluoroscopy time was 13.58 ± 5.35 minutes, mean procedure time was 48.50 ± 22.5 minutes, and mean radiation dose was 1719.5 ± 1217.6 mGycm². Mean time for cutdown was 9.9 ± 2.4 minutes and for haemostasis and suturing was 25.3 ± 11.0 minutes. Median duration of ventilation post-stenting was 26 hours (interquartile range 21-43.75). The median ICU stay post-procedure was 5 days (interquartile range 4-7.25) and mean hospital stay was 12 ± 6.3 days. On early follow-up, carotid patency was confirmed in all patients with colour Doppler, with no intravascular thrombi, narrowing, haematomas, or aneurysms noted. There were no complications secondary to vascular access. There was one early mortality, 27 days post-stenting, which was unrelated to the procedure.

CONCLUSION

This study adds to the limited literature on ductal stenting with carotid access and the flip technique. In our early experience, the hybrid carotid approach is an attractive alternative to percutaneous carotid puncture and has simplified a complex and challenging intervention, with good outcomes.

Short- and medium-term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct-dependent pulmonary circulation

BACKGROUND

Morbidity with surgical systemic-to-pulmonary artery shunting (SPS) in infants ≤2.5 kg has remained high. Patent ductus arteriosus (PDA) stenting may be a valid alternative. The objective of this study is to evaluate outcomes following PDA stenting in patients ≤2.5 kg from four large tertiary centers.

METHODS

Retrospective review of all neonates ≤2.5 kg with duct-dependent pulmonary circulation who underwent PDA stenting. Procedural details, pulmonary arterial growth, reinterventions, surgery type, and outcomes were assessed.

RESULTS

PDA stents were implanted in 37 of 38 patients attempted (18 female) at a median procedural weight of 2.2 kg (interquartile range [IQR], 2-2.4 kg). Seven patients (18%) had a genetic abnormality and 16 (42%) had associated comorbidities. The median intensive care unit stay was 4 days (IQR, 2-6.75 days), and the median hospital stay was 20 days (IQR, 16-57.25). One patient required a rescue shunt procedure, with three others requiring early SPS (<30 days postprocedure). Twenty patients (54%) required reintervention with either balloon angioplasty, restenting, or both. At 6-month follow-up, right pulmonary artery growth (median z-score -1.16 to 0.01, p = 0.05) was greater than the left pulmonary artery (median z-score -0.9 to -0.64, p = 0.35). Serious adverse effects (SAEs) were seen in 18% (N = 7) of our cohort. One patient developed an SAE during planned reintervention There were no intraprocedural deaths, with one early procedure-related mortality, and three interstage mortalities not directly related to PDA stenting.

CONCLUSIONS

PDA stenting in infants ≤2.5 kg is feasible and effective, promoting pulmonary artery growth. Reintervention rates are relatively high, though many are planned to allow for optimal growth before a definitive operation.

Transcatheter Cardiac Interventions in the Newborn: JACC Focus Seminar

For neonates with critical congenital heart disease requiring intervention, transcatheter approaches for many conditions have been established over the past decades. These interventions may serve to stabilize or palliate to surgical next steps or effectively primarily treat the condition. Many transcatheter interventions have evidence-based records of effectiveness and safety, which have led to widespread acceptance as first-line therapies. Other techniques continue to innovatively push the envelope and challenge the optimal strategies for high-risk neonates with right ventricular outflow tract obstruction or ductal-dependent pulmonary blood flow. In this review, the most commonly performed neonatal transcatheter interventions will be described to illustrate the current state of the field and highlight areas of future opportunity.

Comparison of Patent Ductus Arteriosus Stent and Blalock-Taussig Shunt as Palliation for Neonates with Sole Source Ductal-Dependent Pulmonary Blood Flow: Results from the Congenital Catheterization Research Collaborative

Patent ductus arteriosus (PDA) stenting is an accepted method for securing pulmonary blood flow in cyanotic neonates. In neonates with pulmonary atresia and single source ductal-dependent pulmonary blood flow (SSPBF), PDA stenting remains controversial. We sought to evaluate outcomes in neonates with SSPBF, comparing PDA stenting and surgical Blalock-Taussig shunt (BTS). Neonates with SSPBF who underwent PDA stenting or BTS at the four centers of the Congenital Catheterization Research Collaborative from January 2008 to December 2015 were retrospectively reviewed. Reintervention on the BTS or PDA stent prior to planned surgical repair served as the primary endpoint. Additional analyses of peri-procedural complications, interventions, and pulmonary artery growth were performed. A propensity score was utilized to adjust for differences in factors. Thirty-five patients with PDA stents and 156 patients with BTS were included. The cohorts had similar baseline characteristics, procedural complications, and mortality. Interstage reintervention rates were higher in the PDA stent cohort (48.6% vs. 15.4%, p < 0.001).

Factors Influencing Reintervention Following Ductal Artery Stent Implantation for Ductal-Dependent Pulmonary Blood Flow: Results From the Congenital Cardiac Research Collaborative

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) is an established palliative option for infants with ductal-dependent pulmonary blood flow. Following initial palliation, reintervention on the PDA stent is common, but risk factors have not been characterized.

METHODS

Infants with ductal-dependent pulmonary blood flow palliated with PDA stent between 2008 and 2015 were reviewed within the Congenital Cardiac Research Collaborative. Rates and risk factors for reintervention were analyzed.

RESULTS

Among 105 infants who underwent successful PDA stenting, 41 patients (39%) underwent a total of 53 reinterventions on the PDA stent, with all but one occurring within 6 months of the initial intervention. Stent redilation constituted the majority of reintervention (n=35; 66%) followed by additional stent placement (n=11; 21%) and surgical shunt placement (n=7; 13%). The majority of reintervention was nonurgent, and there were no deaths during the reintervention procedure. All but one reintervention occurred within 6 months of the initial procedure. On univariate analysis, risk factors for reintervention included anticipated single-ventricle physiology, lack of prior balloon pulmonary valvuloplasty, use of drug-eluting stent, and increased ductal tortuosity.

CONCLUSIONS

In infants with ductal-dependent pulmonary blood flow palliated with PDA stent implantation, reintervention is common, can be performed safely, and is associated with both anatomic/procedural factors and anticipated final physiology.

Direct carotid artery access for neurointerventional procedures in infants

BACKGROUND

Femoral access is the primary route for neurointerventional procedures in children. However, endovascular treatment may not always be possible through a femoral approach, necessitating conversion to alternative access routes.

OBJECTIVE

To review the feasibility and safety of direct carotid puncture (DCP) in infants undergoing neuroendovascular interventions.

METHODS

We conducted a retrospective review of all infants who underwent DCP as the access route to treat neuroendovascular pathologies between January 2011 and January 2021. Patients' demographics, clinical presentation, imaging findings, and technical details were reviewed.

RESULTS

Between January 2011 and January 2021, five infants aged between 28 and 150 days underwent DCP out of 1129 neuroendovascular interventions performed in our institution (0.4%). All five infants (100%) were diagnosed with intracranial fistulas and were found to have severe tortuosity of the cervical arteries. DCP was performed as the initial access route in 2/5 patients and as crossover after a failed femoral attempt in 3/5 patients. DCP was performed under ultrasound guidance in all patients. Closure was performed by manual compression, without complications. Ultrasound showed patent cervical vessels in all patients at 3 months' follow-up.

CONCLUSION

Direct carotid access is a feasible and safe alternative route to treat neuroendovascular pathologies in infants and can be considered in cases of inaccessible or failed transfemoral access or in cases with severe arterial tortuosity in infants with intracranial fistulas.

Evaluation of carotid artery access in comparison with femoral artery access in neonatal percutaneous stenting of ductus arteriosus

BACKGROUND

Patent ductus arteriosus stenting in duct-dependent pulmonary circulation is a challenging procedure. Percutaneous carotid artery access for ductal stenting has proven to be feasible; however, comparison with femoral artery access in terms of procedure details and complications either immediate or late is scarce. Therefore, we evaluated carotid artery access in comparison with femoral artery for stenting of patent ductus arteriosus.

METHODS

Forty neonates were reviewed, 20 were stented via carotid artery access, and 20 via the traditional femoral artery access. Comparison variables were neonatal demographics at the procedure, angiographic ductal anatomy, procedure details, and immediate complications. Follow-up Doppler ultrasound on access site was performed to document late complications.

RESULTS

Median age of included cases was 10.5 (3-28) days with complex ductal anatomy more frequently accessed via carotid artery than femoral. Immediate access-related complications were significantly higher with femoral than carotid artery access; 9 (45%) versus 3 (15%) respectively, p = 0.038. With carotid access, we had only one case with small pseudoaneurysm and acute hemiparesis 3 days after the procedure. Delayed local complications were more common with femoral access (15%) than carotid access (5%), mild stenosis in one case, and severe in another with femoral access; while with transcarotid arterial access, only one case had mild narrowing.

CONCLUSION

Percutaneous carotid artery access in neonates is a more convenient approach for patent ductus arteriosus stenting especially with complex ductal anatomy. Moreover, local complications are limited and vascular patency is better preserved, in comparison with trans-femoral arterial access. However, the potential for neurological adverse events should not be overlooked.

Technical Modifications for Ductal Stenting in Neonates with Duct-Dependent Pulmonary Circulation

The ductal stenting (DS) is currently an acceptable palliative treatment in newborns suffering with duct-dependent pulmonary circulation. However, this procedure remains technically a challenge in complex ductal morphology, which may eventually lead to detrimental outcomes. This review is mainly focused on pre-procedural planning, essential instruments and practical approaches for DS, and post-procedural care.

Direct percutaneous transcarotid approach for embolization of dural sinus malformation in a premature neonate: A case report

CONCLUSIONS

Direct percutaneous TCAA can be a feasible access for intracranial interventions in neonates with LBW and unavailable UA access.

Hybrid Approach for Embolized Right Ventricular Outflow Tract Stent

Displacement and embolization of the stent is one of the major complications of right ventricular outflow tract (RVOT) stenting. Since embolized stents cannot be retrieved percutaneously as they cannot be crimped into pre-stenting state (unlike duct occluders and septal devices, which can be pulled back into the sheath), surgery remains the gold standard treatment. We describe a hybrid approach for the retrieval of the embolized RVOT stent, which will decrease morbidity when compared to the standard surgical approach that is otherwise required.

Rerouting of Cerebral Circulation

We describe an adolescent with long-standing atresia of the head/neck arteries and severe aortic coarctation. Because of progressive symptoms, a series of interventions was undertaken to provide direct aorta–to–carotid artery flow and coarctation treatment. This case highlights the unusual physiological features associated with atresia of all head and neck arteries. (Level of Difficulty: Advanced.)

Advances in Pediatric Ductal Intervention: an Open or Shut Case?

PURPOSE OF REVIEW

To review the most recent literature on pediatric transcatheter ductal intervention including ductus arteriosus occlusion and stenting.

RECENT FINDINGS

With the development and FDA approval of smaller ductal devices, including most recently the Amplatzer Piccolo Occluder (Abbott, Abbott Park, IL), transcatheter ductus arteriosus device closure is now being safely performed in premature infants and patients < 6 kg using a transvenous approach. In patients with ductus-dependent pulmonary blood flow, ductal stenting with pre-mounted coronary artery stents has been shown to be an acceptable alternative to the surgically placed Blalock-Taussig shunt. Centers with experience in ductal stenting have demonstrated success, even with the tortuous ductus. Innovation in transcatheter device technology and procedural practices have allowed for significant advances. Transcatheter ductal device closure is a reasonable alternative to surgical ligation even in premature, low-birthweight infants. Ductal stenting is also an accepted alternative to the modified Blalock-Taussig shunt. We anticipate continued advancement and procedural refinement over the next several years.

Transcatheter ductus arteriosus stenting in paediatric cardiology: Indications, results and perspectives

Stenting the arterial duct emerged in the early 1990s as an alternative to a variety of surgical interventions in neonates with a duct-dependent pulmonary or systemic circulation complex defect. Furthermore, palliative ductal stenting has been applied in older children with severe suprasystemic pulmonary arterial hypertension, as an alternative to surgical shunts, such as Potts anastomosis. Early results of this technique were discouraging, but by learning from the failures of the past, ductal stenting has become a reliable palliative therapy. In this review, we aim to describe the historical evolution of ductal stenting, its different clinical applications and outcomes, and future perspectives for this strategy in congenital cardiac catheterization.

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.

Indications and results for hybrid interventions in patients with congenital heart disease

A hybrid therapy or procedure is a new treatment modality that develops by combining therapies from different subspecialties. In congenital heart disease, a growing number of such procedures have been described in recent decades, as a result of increasing collaboration between surgeons and interventionalists. The ideas behind these therapies include enabling the performance of procedures of different complexity in a less invasive manner, shortening procedural times, avoiding cardiopulmonary bypass, facilitating vascular access and decreasing the number of complications associated with more invasive approaches. Over the years, hybrid therapy has gained a place as a widely accepted therapeutic option for the management of several conditions in high-risk patients with congenital heart disease.

Microcatheter-assisted stenting of the tortuous vertical ductus arteriosus via femoral access in a duct-dependent pulmonary circulation

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) has been accepted as alternative option to surgical shunting to enable additional pulmonary blood flow or for palliation of patients with a truly duct-dependent pulmonary circulation. The procedure can be challenging given the variable and often tortuous anatomy of the PDA and various technical approaches are reported.

OBJECTIVE

To report an alternative technique to treat tortuous ducts with microcatheter assistance and by transfemoral approach.

METHODS

We applied this technique of PDA stenting in 5 consecutive patients (4/5 age < 1 week, weight 2,7-3,2 kg; 1/5 re-do PDA stenting at 6,5 month and 5,9 kg). A soft coronary guidewire was advanced by microcatheter assistance into the branch pulmonary arteries and thereafter replaced by an extrastiff guidewire to enable the placement of long coronary stents.

RESULTS

Successful PDA stenting with this stepwise approach and with femoral access only could be achieved in all patients (n = 5/5). A single stent was used in 2 patients (one with re-do stenting and previous stents). 3/5 patients had 2 stents implanted by telescopic technique. Stent sizes used were 4,5 × 15 mm (n = 2) and 4,5 × 18 mm (n = 6). No guide wire or stent dislodgement appeared through all procedures with microcatheter assistance.

CONCLUSIONS

This technique enables PDA stenting via transfemoral approach in complex and tortuous ducts and thereby offers an attractive addition to the interventional management of truly duct-dependent pulmonary circulation.

Percutaneous ultrasound guided thrombin injection for axillary artery pseudoaneurysm following stenting of the arterial duct in two infants: Case report with review of literature

We report pseudoaneurysm of the axillary artery following stenting of the arterial duct in two infants. They were both successfully managed by ultrasound guided thrombin injection with preservation of native arterial flow. We also review the relevant literature.

Recent advances in managing vascular occlusions in the cardiac catheterization laboratory

Vascular occlusions continue to be a significant cause of morbidity and mortality. The management of vascular occlusions in patients is complex, requiring specialized expertise in the cardiac catheterization laboratory and from other disciplines. Knowledge of currently available tools at the operator’s disposal is important to optimize the success of these procedures. In this review, we discuss some of the recent advances in recanalization procedures of vascular occlusions and thrombotic lesions in the cardiac catheterization laboratory.

Measurement variability of right atrial and ventricular monophasic action potential and refractory period measurements in the standing non-sedated horse

BACKGROUND

In human and veterinary medicine, monophasic action potential (MAP) analysis and determination of local refractory periods by contact electrode technique gives valuable information about local cardiac electrophysiological properties. It is used to investigate dysrhythmias and the impact of drugs on the myocardium. Precise measurement of total MAP duration is difficult, therefore the MAP duration is usually determined at a repolarization level of 90% (APD90). Until now, no studies are published about the feasibility of this technique in the standing non-sedated horse. In 6 healthy Warmblood horses, on two different days, an 8F quadripolar contact catheter was passed through a jugular introducer sheath and placed under ultrasound guidance at the level of the intervenous tubercle or right atrial free wall (RA), and in the right ventricular apex (RV) to record the MAP. The MAP amplitude and APD90 were measured at a resting sinus rhythm (heart rate of 30-42 bpm) and at pacing cycle lengths (PCL) of 1000 and 600 ms. The effective refractory period (ERP) was determined at PCL of 1000 and 600 ms.

RESULTS

The overall mean (±SD) APD90 (rest), APD90 (1000) and APD90 (600) were 263 ± 39 ms, 262 ± 41 ms, 236 ± 47 ms for the RA and 467 ± 23 ms, 412 ± 38 ms, 322 ± 29 ms for the RV. The mean ERP1000 and ERP600 were 273 ± 24 ms and 256 ± 22 ms for the RA and 386 ± 40 ms and 293 ± 30 ms for the RV. The measurement variability for the amplitude, APD90 and ERP measurements in the RA ranged between 36 and 44, 9-22 and 7-8%, respectively. The measurement variability for the amplitude, APD90 and ERP measurements in the RV ranged between 49 and 66, 6-7 and 10-12%, respectively.

CONCLUSIONS

RA and RV MAP duration and ERP can be obtained by a contact electrode in standing non-sedated horses. The measurement variability varies with catheter location.

A Comparison of Anterograde Versus Retrograde Approaches for Neonatal Balloon Aortic Valvuloplasty

In neonates requiring balloon aortic valvuloplasty, both anterograde and retrograde approaches are feasible. A recent comparison of these two approaches is lacking. A retrospective cohort study of neonates at a single center undergoing BAV from 9/00 to 7/14 was performed. Records were reviewed including pre- and post-intervention echocardiograms and catheterization data. Comparisons of acute efficacy and procedural safety were made based on type of approach utilized. Forty-two neonates underwent BAV. Eleven cases utilized exclusively an anterograde approach, while 31 included a retrograde approach (including 4 with both approaches used). There were no significant differences between groups in baseline demographic and clinical characteristics. Additionally, by both pre-intervention echocardiogram and catheterization, there were no differences based on approach in aortic valve gradient, degree of aortic insufficiency (AI), or degree of mitral regurgitation (MR). Both approaches were equally efficacious in gradient reduction (45 ± 17 vs. 44 ± 21 mmHg, p = 0.97), and there was no difference in post-intervention AI as assessed by both catheterization and echocardiogram (52% vs. 64% none or trivial, p = 0.74). Additionally, there was no difference in the proportion of patients with an increased severity of MR after BAV (15% vs. 22%, p = 0.52). The retrograde approach required a larger arterial catheter and was associated with a higher rate of arterial thrombosis (61% vs. 18%, p = 0.014). Both anterograde and retrograde approaches to neonatal BAV appear to be equally efficacious in the short term. The anterograde approach avoids the need for a larger arterial catheter and may reduce the risk of arterial thrombosis.

Comparison Between Patent Ductus Arteriosus Stent and Modified Blalock-Taussig Shunt as Palliation for Infants With Ductal-Dependent Pulmonary Blood Flow

Background:

Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or a modified Blalock-Taussig (BT) shunt. A balanced multicenter comparison of these 2 approaches is lacking.

Methods:

Infants with ductal-dependent pulmonary blood flow palliated with either a PDA stent or a BT shunt from January 2008 to November 2015 were reviewed from the 4 member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared by use of propensity score adjustment to account for baseline differences between groups.

Results:

One hundred six patients with a PDA stent and 251 patients with a BT shunt were included. The groups differed in underlying anatomy (expected 2-ventricle circulation in 60% of PDA stents versus 45% of BT shunts; P =0.001) and presence of antegrade pulmonary blood flow (61% of PDA stents versus 38% of BT shunts; P <0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio, 0.8; 95% confidence interval [CI], 0.52–1.23; P =0.31). Other reinterventions were more common in the PDA stent group (hazard ratio, 29.8; 95% CI, 9.8–91.1; P <0.001). However, the PDA stent group had a lower adjusted intensive care unit length of stay (5.3 days [95% CI, 4.2–6.7] versus 9.19 days [95% CI, 7.9–10.6]; P <0.001), a lower risk of diuretic use at discharge (odds ratio, 0.4; 95% CI, 0.25–0.64; P <0.001) and procedural complications (odds ratio, 0.4; 95% CI, 0.2–0.77; P =0.006), and larger (152 mm 2 /m 2 [95% CI, 132–176] versus 125 mm 2 /m 2 [95% CI, 113–138]; P =0.029) and more symmetrical (symmetry index, 0.84 [95% CI, 0.8–0.89] versus 0.77 [95% CI, 0.75–0.8]; P =0.008] pulmonary arteries at the time of subsequent surgical repair or last follow-up.

Conclusions:

In this multicenter comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow adjusted for differences in patient factors, there was no difference in the primary end point, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.

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.

Recurrent coarctation of aorta after Norwood operation in single ventricle patients; the case of the missing ideal stent

Recurrent coarctation postoperative Norwood is poorly tolerated in single ventricle patients. Although transcatheter balloon angioplasty is considered first line, it often leads to inadequate or non-durable relief of obstruction. Transcatheter stent implantation provides excellent relief of obstruction but necessitates staged redilation to account for somatic growth in children. Stent technology, delivery systems, and procedural techniques will need to evolve to obviate reported adverse events mainly due to patient size.

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.