Selective Photocoagulation of Placental Vessels in Twin-Twin Transfusion Syndrome

Quintero, Rubén A.; Morales, Walter J.; Mendoza, Gustavo A.; Allen, Mary; Kalter, Craig S.; Giannina, Gregg; Angel, Jeffrey L.

doi:10.1097/00006254-199812010-00001

Cited by 159 publications

(117 citation statements)

References 11 publications

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“…However, intrauterine fetal demise of one of the two fetuses after SLPCV would still occur in approximately 9-29% of cases with this technique (Quintero et al, 1998;R. Quintero, C. Comas, 2000).…”

Section: Functional Ablation Of the Placental Vascular Anastomoses: Tmentioning

confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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Objective: Laser ablation of all placental vascular anastomoses is the optimal treatment for twin-twin transfusion syndrome (TTTS). However, two important controversies are apparent in the literature: (a) a gap between concept and performance, and (b) controversy regarding whether all the anastomoses can be identified endoscopically and whether blind lasering of healthy placenta is justified. The purpose of this article is: (a) to address the potential source of the gap between concept and performance by analyzing the fundamental steps needed to successfully accomplish the surgery, and (b) to discuss the resulting competency benchmarks reported with the different surgical techniques. Materials and Methods: Laser surgery for TTTS can be broken down into two fundamental steps: (1) endoscopic identification of the placental vascular anastomoses, (2) laser ablation of the anastomoses. The two steps are not synonymous: (a) regarding the endoscopic identification of the anastomoses, the non-selective technique is based upon lasering all vessels crossing the dividing membrane, whether anastomotic or not. The selective technique identifies and lasers only placental vascular anastomoses. The Solomon technique is based on the theory that not all anastomoses are endoscopically visible and thus involves lasering healthy areas of the placenta between lasered anastomoses, (b) regarding the actual laser ablation of the anastomoses, successful completion of the surgery (i.e., lasering all the anastomoses) can be measured by the rate of persistent or reverse TTTS (PRTTTS) and how often a selective technique can be achieved. Articles representing the different techniques are discussed. Results: The non-selective technique is associated with the lowest double survival rate (35%), compared with 60-75% of the Solomon or the Quintero selective techniques. The Solomon technique is associated with a 20% rate of residual patent placental vascular anastomoses, compared to 3.5-5% for the selective technique (p < .05). Both the Solomon and the selective technique are associated with a 1% risk of PRTTTS. Adequate placental assessment is highest with the selective technique (99%) compared with the Solomon (80%) or the 'standard' (60%) techniques (p < .05). A surgical performance index is proposed. Conclusion: The Quintero selective technique was associated with the highest rate of successful ablation and lowest rate of PRTTTS. The Solomon technique represents a historical backward movement in the identification of placental vascular anastomoses and is associated with higher rate of residual patent vascular communications. The reported outcomes of the Quintero selective technique do not lend support to the existence of invisible anastomoses or justify lasering healthy placental tissue.

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Section: Functional Ablation Of the Placental Vascular Anastomoses: Tmentioning

confidence: 99%

Laser Treatment of Twin–to–Twin Transfusion Syndrome

2016

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“…Our group has developed criteria for diagnosis and classification of the disease that are widely used to stage and treat this disorder worldwide 16 . We have also developed the technique of selective laser photocoagulation 8 , which has now become the method of choice for the treatment of patients with twin-twin transfusion syndrome 17 . Unfortunately, Dr Fisk's group has contributed to the creation of an unhealthy mythology about the disease promulgating hypotheses that have not stood up to the rigors of scientific scrutiny.…”

Section: Taylor Et Al Question the Reason For Selecting Patientsmentioning

confidence: 99%

Late onset microcephaly: failure of prenatal diagnosis

Ray

Viot

Tsatsaris

et al. 2004

Ultrasound in Obstet & Gyne

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“…Numerous treatment options for TTTS have been reported, including amnioreduction (AR) [6][7][8][9][10][11][12] , intertwin septostomy [13][14][15][16] , non-selective fetoscopic laser [17][18][19][20] selective fetoscopic laser photocoagulation (SFLP) [21][22][23][24][25][26][27][28] , and cord coagulation [29][30][31][32] , all of which have improved survival rates compared to the untreated natural history of TTTS. It has been controversial which of these treatment options would provide the best outcome in specific cases of TTTS.…”

Section: Introductionmentioning

confidence: 99%

“…Subsequently, Quintero et al, recognizing there is no anatomic relationship between the position of the intertwin membrane and the vascular equator, described a selective technique of fetoscopic laser photocoagulation in which only vessels demonstrated to be communicating between the two twins are treated 21 . This selective fetoscopic laser technique is thought to preserve non-communicating vessels and has been associated with survival rates of 62 to 77% [21][22][23][24][25][26][27][28] .…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome

Crombleholme

Shera

Lee

et al. 2007

American Journal of Obstetrics and Gynecology

160

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Objective-To examine the effect of selective fetoscopic laser photocoagulation (SFLP) versus serial amnioreduction (AR) on perinatal mortality in severe twin-twin transfusion syndrome (TTTS).Study Design-5-year multicenter prospective randomized controlled trial. The primary outcome variable was 30-day postnatal survival of donors and recipients.Results-There is no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11/20) vs 55% (11/20) (p=1, OR=1, 95%CI=0.242 to 4.14) or Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. 35% (7/20) (p=0.25, OR=5.31, 95%CI=1.19 to 27.6). This is offset by increased recipient neonatal mortality of 30% (6/20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality (p=0.055, OR=3.025/point) by logistic regression analysis. NIH Public AccessConclusions-The outcome of the trial does not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.

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Selective Photocoagulation of Placental Vessels in Twin-Twin Transfusion Syndrome

Cited by 159 publications

References 11 publications

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Laser Treatment of Twin–to–Twin Transfusion Syndrome

Late onset microcephaly: failure of prenatal diagnosis

A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome

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