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

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.

Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review

Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.

Axillary arterial access for balloon dilatation of coarctation of aorta in newborns: a case series

Balloon dilatation of coarctation of aorta is a standard of care for the patients presenting with severe left ventricular dysfunction. It can be performed through femoral, carotid, and axillary arterial access. Very few case series were available in the literature through axillary arterial access, despite being its advantage as non-end artery and easily palpable in coarctation of aorta. We present our experience with five cases of neonatal coarctation of aorta with severe left ventricular dysfunction where successful balloon dilatation of coarctation of aorta was performed via axillary approach without adverse events.

Challenges in diagnosis and management of coarctation of the aorta

PURPOSE OF REVIEW

Coarctation of the aorta remains a controversial topic with uncertainties in long-term outcomes.

RECENT FINDINGS

Recent advances in fetal imaging including echocardiography and MRI offer novel opportunities for better detection and prediction of the need for neonatal intervention.New imaging techniques are providing novel insights about the impact of arch geometry and size on flow dynamics and pressure gradients. The importance of arch size rather than shape for optimal hemodynamics has been identified. Long-term outcome data suggest a significant increase in mortality risk in coarctation patients beyond the third decade when compared with the general population. Hypertension is highly prevalent not only in adult patients following repair of coarctation but also in normotensive patients presenting with LV diastolic dysfunction and adverse remodelling, indicating that abnormal vascular properties are important. Patients with coarctation undergoing neonatal repair are at risk for adverse neurodevelopmental outcomes and patients could benefit from timely neurocognitive evaluation and intervention.

SUMMARY

Optimizing aortic arch size, prevention and aggressive treatment of hypertension and vascular stiffening are important to improve long-term outcomes.

Simplify long-term venous access via external jugular vein in children

Background

Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study.

Results

No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%.

Conclusions

The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.

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.