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

Abstract

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.

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

“…25 diseases, 34 these PDAs can occasionally be accessed through the femoral vein via the right ventricle, ventricular septal defect, and ascending aorta. 35 However, as this pathway may be associated with hemodynamic instability in infants (and requires suitable anatomy), 35 nonfemoral approaches have recently gained favor as potentially more efficient approaches for vertical PDAs.…”

“…Although there is a paucity of large-scale data on vascular access for PDA stenting, multiple smaller observational studies present promising outcomes for the carotid and axillary arteries, particularly for approaching vertical PDAs through the superior aspect of the aortic arch. 25,30,[35][36][37][38][39][40][41] Bauser-Heaton et al 36 observed that carotid and axillary artery access is more commonly used in highly tortuous PDAs than the femoral artery and that procedural and late complications were similar regardless of the access site. Similarly, Alsawah et al 37 reported that percutaneous carotid access was more commonly used in complex ductal anatomy, and they found that both immediate access-related complications and delayed local complications in these cases were significantly lower than in cases that used the femoral artery.…”

“…Little is known about the relative benefits and drawbacks of percutaneous carotid access versus surgical cut-down. Sen et al 35 percutaneous carotid access could increase the risk of thrombosis, occlusion, or pseudoaneurysm and that it can be difficult to find a balance between anticoagulation for stent patency versus carotid hemostasis. For this reason, their institution prefers surgical cut-down.…”

“…42 This position more closely mimics the familiar conventional orientation while approaching from a superior direction, and it allows the operator to have full access to the table for adequately stabilizing the sheath and wire position, which can be paramount while stenting tortuous ducts. 35,36 It may also ease wire and catheter exchanges, which can be critical in cases of hemodynamic instability or other complications. 38 In addition, Bauser-Heaton et al 36 found that the flip technique was associated with shorter procedure times for highly tortuous PDAs, although this did not reach statistical significance.…”

The effectiveness of the flip technique in vertical ductal stenting

“…[ 16 , 19 ] These alternative routes allow the practitioner to directly visualize the DA and to complete the procedure with fewer complications. [ 20 ] In our practice, we decide the route after the echocardiographic examination of ductus anatomy. In cases where we decide to use the carotid artery route, we perform the sheath placement process under ultrasound guidance in the safest way.…”