Transcatheter closure through single venous approach for young children with patent ductus arteriosus: A retrospective study of 686 cases

How to Avoid Arterial Access During Transcatheter Closure of Patent Ductus Arteriosus Using Anatomo-haemodynamic Landmark

Objective

To evaluate the feasibility, safety, and efficacy of transcatheter closure (TCC) of patent ductus arteriosus (PDA) using anatomo-haemodynamic landmark without any arteriography.

Method

In this prospective, non-randomized study, all consecutive patients with PDA undergoing transcatheter closure at LPS Institute of Cardiology, Kanpur, India between January 2019 and June 2024 were evaluated. TCC was performed using anatomical and haemodynamicl landmark without aortogram, and device was deployed through antegrade route only. Transthoracic echocardiography with colour-Doppler imaging was used to confirm position of the device before final deployment. Primary outcome was procedural and fluoroscopy time, and major complications (access site complications, device embolization, residual shunt ≥ grade 3, haemolysis, flow acceleration in left pulmonary artery and descending thoracic aorta, and death). Success was defined as complete closure of shunt without any major complications.

Result

TCC was successfully performed through antegrade route in 250 patients (age: 2.3 ± 1.2 years; weight: 10.3 ± 9.8 kg) while 16 patients were excluded for various reasons. Mean diameter of duct was 6.7 ± 4.5 mm. Male and female comprised 176 (70.4%) and 74 (29.6%) respectively. PDA were type A (n = 195; 78%), B (n = 27; 10.8%), C (n = 20; 8%), and (n = 8; 3.2%). TCC was successful in all patients although dislodgement was noted in 1 (0.04%). Lifetech duct occluder and Konar MFO were most commonly used devices in 156 (62.4%) and 33 (13.2%) patients respectively. Immediate closure was achieved in 233 (93.2%) patients while remaining 17 (7.8%) with grade I or II shunt on echocardiogram had complete closure in 2 days. Device embolization was observed in 1 (0.4%) patient while flow acceleration in DTA were observed in 5 (2%) patients. Procedure was successful in 99.6% using antegrade while TCC using isolated venous route was successful in 94%.

Conclusion

TCC of PDA using anatomo-haemodynamic landmark and avoiding arterial access is feasible, safe, and effective, with excellent results on short and medium-term follow-up.

Transcatheter Closure of Ventricular Septal Defects after Upfront Transvenous Antegrade Cannulation from the Right Ventricle

Transcatheter closure (TCC) of certain ventricular septal defect (VSD) subtypes typically requires arteriovenous loop (AVL) formation or retrograde transarterial deployment. Upfront transvenous cannulation from the right ventricle avoids arterial access and loop-related complications. We retrospectively reviewed data of patients who underwent TCC for perimembranous, intraconal, and post-surgical residual VSDs at our institution (January 2019-December 2023). Patients receiving upfront transvenous VSD cannulation and closure were compared to those undergoing antegrade closure after AVL formation. Upfront retrograde closure cases were excluded. In a cohort of 163 patients, upfront transvenous cannulation was performed in 116 (71%) and AVL formation in 31 (19%). Upfront transvenous cannulation use increased from 25.6% in 2019 to 93% in 2023. For the upfront group, the median patient age was 55 months (IQR, 17.8-120.8), median weight was 15.8 kg (IQR, 9.6-29.8), indexed VSD size was 9.2 mm/m2 (IQR, 5.5-14.8), and 68.9% had pulmonary arterial hypertension. Cannulation was successful in 83.6% (97/116) of cases, with a switch to retrograde transarterial cannulation in 16.4% (19/116). No deaths or pacemaker implantations occurred. Compared to AVL group, upfront group had significantly shorter procedural times (p = 0.002) and lower radiation exposure (p < 0.001). Smaller patient weight (OR: 0.97, 95%CI: 0.95-0.99), larger indexed VSD size to patient weight (OR: 36.5, 95%CI: 2.49-533.9) and to BSA (OR: 1.23, 95%CI: 1.06-1.4) were significant independent predictors for successful transvenous cannulation. Upfront transvenous VSD cannulation simplifies transvenous TCC by eliminating the need for arterial access and AVL formation, particularly successful in small patients with large defects.

Application of single venous approach under echocardiography without angiography in closure of Patent Ductus Arteriosus

BACKGROUND

The conventional arteriovenous approach closure of patent ductus arteriosus (PDA) may be associated with more complications, especially in young infants. The objective is to explore the feasibility and clinical efficacy of interventional closure of PDA through a single venous approach under echocardiography without angiography.

METHODS

112 patients (32 males and 80 females) with PDA closed by different methods in Suining Central Hospital were enrolled, including 60 cases (Group 1) with a single venous approach under echocardiography without angiography and 52 cases (Group 2) with the conventional arteriovenous approach. There were no significant differences in age and gender composition between the two groups. The success rate of operation, complete closure rate of 24 h, procedure time, X-ray fluoroscopic time, radiation dose, intraoperative contrast volume, preoperative and postoperative creatinine, preoperative and postoperative uric acid nitrogen, bed rest time, total hospital stay, and incidence of vascular complications were compared between the two groups.

RESULTS

There were no significant differences in the success rate of operation (100% vs. 100%) and the complete closure rate of 24 h (100% vs. 100%) between the two groups (P > 0.05). In the single venous approach group, the procedure time was (50.05 ± 4.78 min vs. 57.69 ± 6.44 min), the X-ray fluoroscopy time was (7.30 ± 0.78 min vs. 10.23 ± 1.58 min), and the radiation dose was (79.57 ± 15.18mGy vs. 219.22 ± 34.60mGy), contrast volume (0mL vs. 62.22 ± 22.69 ml), bed rest time (4.03 ± 0.99 h vs. 12.25 ± 1.73 h), total hospital stay (3.30 ± 0.52 days vs. 3.39 ± 0.49 days) and the incidence of vascular complications (0% vs. 13.9%) were significantly lower than those in the traditional angiography group (P < 0.05). There were no significant changes in creatinine (51.86 ± 12.75 umol/L vs. 53.09 ± 10.27 umol/L) and urea nitrogen (4.84.81 ± 1.21 mmol vs. 4.98 ± 0.93 mmol/L) before and after operation in single venous group (P > 0.05). Compared with preoperative creatinine level (68.23 ± 8.66umol vs. 59.23 ± 22.12umol) and urea nitrogen level (5.98 ± 1.13 mmol/L vs. 5.16 ± 1.49 mmol/L) in the traditional angiography group after operation (24 h), they were significantly increased (P < 0.05).

CONCLUSIONS

Compared with the conventional arteriovenous approach, the single venous approach has the outstanding advantage of reducing vascular complications, contrast volume, radiation dose, and procedure time. Compared with the conventional arteriovenous approach, on the basis of obtaining the same efficacy, the PDA occlusion of the single venous approach under echocardiography without angiography has the outstanding advantages of simplified operation, less X-ray radiation, no contrast agent injury, short bed rest time, and fewer vascular complications. It is a green and safe surgical method worth promoting for PDA patients with suitable anatomical conditions.

Transcatheter Closure of Patent Ductus Arteriosus via Different Approaches

Background: There have been marked advances in devices such as Amplatzer Duct Occluder II (ADO-II) or vascular plug through 5Fr delivery sheath for closure of patent ductus arteriosus (PDA) in the past five decades, making it possible for cardiologists to deliver occluders via different approaches. However, comparisons of these different approaches have not been reported. Therefore, the aim of this study was to summarize and compare the advantages of different approaches for PDA closure, and to guide clinical strategies.

Methods: This retrospective study included all patients undergoing transcatheter closure of PDA from 2019 to 2020. Patients were matched by 1:1 propensity score matching (PSM). The retrograde femoral artery approach (FAA) and simple vein approach (SVA) groups were compared with the conventional arteriovenous approach (CAA).

Results: The average age of the 476 patients was 21.05 ± 21.15 years. Their average weight was 38.23 ± 24.1 kg and average height was 130.14 ± 34.45 cm. The mean diameter of the PDA was 4.29 ± 2.25 mm. There were 127 men and 349 women, comprising 205 adults and 271 children. Among them, 197 patients underwent CAA, 223 underwent SVA, and 56 underwent retrograde FAA. The diameter in the FAA group was smaller than that in the other two groups, but was similar in adults and children. In the PSM comparison of CAA and SVA, 136 patients with CAA and 136 patients with SVA were recruited. Simple vein approach was associated with markedly reduced length of hospital stay, length of operation, and contrast medium usage as compared with CAA (all P < 0.05). In the PSM comparison of FAA and CAA, 30 patients with CAA and 30 patients with FAA were recruited. The operation duration was longer in the CAA than in the FAA group. There were no significant differences in postoperative complications among groups.

Conclusion: Patent ductus arteriosus closure by using the SVA and FAA is safe and effective, and has certain advantages in some respects as compared with CAA.

Comparison of isolated venous approach with the standard approach in children undergoing patent ductus arteriosus device closure

BACKGROUND

Transcatheter device closure is a safe procedure recommended in children with patent ductus arteriosus (PDA). While the standard procedure uses arterial and venous femoral access, it poses risk of vascular complications especially in young infants. Isolated venous approach has been tried in a few studies and was found to be non-inferior to the standard technique. In this prospective observational study, we have compared the two vascular approaches of PDA device closure in pediatric patients and have also studied the feasibility of this approach in young children with weight < 6 kg.

RESULTS

PDA device occlusion was performed with either one of the approaches-venous alone (group I) or standard approach (group II) in a total of 135 children enrolled prospectively. The baseline data, procedural outcomes, vascular complications, and radiation dose were compared between the two groups. Fifty-two and 83 children were included in group I and group II, respectively. A total of 22 children (16%) (13 in group I; 9 in group II) had weight < 6 kg. In group II, 6 children (7.2%) had vascular site complications treated with heparin infusion with two children requiring thrombolysis. Another child in group II developed intravascular hemolysis following residual shunt, requiring surgical device retrieval and closure. No significant differences were observed in mean fluoroscopic time (p = 0.472) and air kerma between the two groups (p = 0.989).

CONCLUSION

Transcatheter PDA device closure without arterial access is a feasible and safe option in children including young infants. This technique avoids the risk of vascular complications although requires careful case selection.