Percutaneous intraluminal downsizing of systemic‐to‐pulmonary artery shunts: a novel application of the Diabolo stent technique—Case series and description of the technique

Abstract

Objective This article aims to describe the feasibility of a novel application of the Diabolo stent technique for percutaneous downsizing of systemic‐to‐pulmonary artery shunts in patients with pulmonary overcirculation. Background Pulmonary overcirculation can lead to systemic hypoperfusion, impaired systemic oxygen delivery, and hemodynamic instability especially in patients with single‐ventricle physiology. Different medical and surgical strategies to treat pulmonary overcirculation have been reported so far, but no percutaneous approach amenable to further adjustment over time has been described. Methods Retrospective review of patients who underwent percutaneous intraluminal reduction of a systemic‐to‐pulmonary artery shunt with a covered stent in a Diabolo “hour‐glass” configuration. Results From July 2018 to February 4, 2019, consecutive patients underwent trans‐catheter downsizing of a systemic‐to‐pulmonary artery shunt. The median age was 3.3 years (range 0.7–5.7 years). All patients had symptomatic pulmonary overflow despite maximal medical therapy. All patients underwent successful implantation of a covered stent in a Diabolo “hour‐glass” configuration without any complications. Successful reduction in pulmonary overcirculation was noted in all patients with a decrease of mean pulmonary artery pressure from a median of 29 mmHg (range 25–32 mmHg) to a median of 21 mmHg (range 14–27 mmHg). Conclusions Percutaneous intraluminal downsizing of systemic‐to‐pulmonary artery shunts with a covered stent in a Diabolo configuration is safe and feasible. With this technique, the pulmonary blood flow can be adjusted in a physiologic closed‐chest condition and further regulated over time.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence

“…Anticoagulant therapy could be considered in cases with thrombotic or in subjects at high risk for thrombotic events. Heparin was given before stenting for all patients with close monitoring of activated clotting time around 200 s ( 66 , 95 ). Post-procedure, continuous intravenous heparin infusion was given and was followed by oral aspirin ( 96 ).…”

“…This delay can go up to a median of 8.8 years as reported by Bonnet et al ( 31 ). Another study showed that shunts downgraded in size with endovascular stenting were all patent at a median follow-up of 7.3 months with no signs or symptoms of pulmonary over-circulation ( 95 ). Also, no procedure-related mortality was reported during follow-up period ( 71 , 90 , 96 ).…”

Novel application of the Diabolo technique to restrict pulmonary blood flow in a single ventricle patient with a right ventricle to pulmonary artery conduit

“…While this technique has been reported in the management of systemic-to-pulmonary artery shunts (weight range 7.3-17 kg), this is the first case, to our knowledge of its use in an RV-PA conduit (weight 3 kg). 8 Disadvantages of this technique include the long delivery sheath, which can potentially lead to hemodynamic instability due to tricuspid regurgitation. In addition, iatrogenic heart block is a known risk during stent placement in Sano (RV-PA) conduits, though did not occur in our case.…”

“…The configuration was comparable with that depicted in fig. 1 of Maschietto et al 8 A 7F × 48 cm Mullins Guiding Sheath (Cook Medical LLC) was advanced over a 0.035'' support wire into the right pulmonary artery. Before removing the dilator, the 0.035'' wire was exchanged for a 0.018'' support wire to accommodate the mounted stent.…”

“…The Diabolo technique to deploy a bare metal or covered stent with an "hour-glass" configuration has been applied in a growing number of clinical scenarios, including stenting the atrial septum, Fontan fenestrations, and downsizing surgical systemic-to-pulmonary artery shunts. [4][5][6][7][8] We present a novel use of the Diabolo stent technique within a right ventricle (RV) to pulmonary artery (PA) conduit to successfully limit excess PBF and improve patient outcome.…”