Stenting the vertical neonatal ductus arteriosus via the percutaneous axillary approach

Abstract

Background/Objective Stenting the ductus arteriosus (DAS) has become an alternative to surgical systemic to pulmonary artery shunts in neonates with ductal‐dependent pulmonary blood flow (PBF). Femoral approach for a vertical ductus can be difficult secondary to the acute angle and tortuous course, thus alternative access sites have been explored. Carotid access complications have been reported in 5%‐10%. The extensive use of an axillary arterial approach in the United States has not been reported. The aim of this study is to describe our experience with DAS using the axillary approach. Methods We reviewed all patients with DAS with an axillary approach in neonates with ductal‐dependent PBF (May 2017‐May 2018) in our institution. Procedural reports, angiograms, and clinical records of all consecutive patients were reviewed. Procedural technique, procedural outcomes, adverse events, and post‐hospital courses are reported. Results Seven consecutive patients who received DAS utilizing axillary approach. All patients had ductal‐dependent PBF through a vertical, tortuous ductus. Five had pulmonary atresia or near atresia, one had compromised PBF due to dynamic subvalvar obstruction, and one had Tetralogy of Fallot with isolated left pulmonary artery. Axillary access with 3.3 or 4 French sheath was obtained using ultrasound guidance. Bare metal coronary stents were deployed successfully in all. Intra‐procedure, one developed in stent thrombus requiring re‐stenting. There were no procedural mortalities or major adverse events from axillary access. There is a steep learning curve. Hemostasis was achieved with manual compression. Two patients had reintervention at 6‐8 weeks. All patients underwent successful planned surgeries. Conclusions This series suggests DAS in neonates utilizing an axillary approach is a feasible and effective alternative for establishing PBF. Axillary arterial approach may be preferred as there is no risk to neurological sequelae and very low risk of limb complications. Larger series are needed to validate this approach.

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

“…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.…”

“…37 Partly in an effort to avoid these potentially devastating neurologic consequences, other interventionists have attempted vertical PDA access through the axillary artery. [38][39][40]42 Although subclavian artery injury is possible with axillary artery access, for many years, classic Blalock-Taussig shunts have sacrificed the subclavian artery with no significant long-term complications. 43 This likely represents the reason that interventionists such as Lee et al 39 prefer the axillary approach.…”

“…[38][39][40]42 Although subclavian artery injury is possible with axillary artery access, for many years, classic Blalock-Taussig shunts have sacrificed the subclavian artery with no significant long-term complications. 43 This likely represents the reason that interventionists such as Lee et al 39 prefer the axillary approach. Breatnach et al 38 described a successful series of PDA stenting via the axillary artery in 20 patients, with 3 access-related complications that were managed conservatively without long-term effects (2 partial dissections to the subclavian artery and a right axillary artery pseudoaneurysm).…”

“…13,18,20,31,38 Rapamycin-eluting stents have been shown to prolong ductal patency in piglets, although this effect decreases with time. 39,45 However, some concern remains over the potential immunosuppressive effects of drug-eluting stents. In a study of neonates receiving sirolimus-eluting stents, peak sirolimus levels reached immunosuppressive levels, although no clinically significant adverse outcomes were observed.…”

Short‐ and medium‐term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct‐dependent pulmonary circulation

“…None of the patients with axillary access developed vascular complications. Several reports have described the axillary approach for PDA stenting and concluded that axillary access provides a safe, direct approach to the PDA, although potential complications can arise particularly pseudoaneurysm formation 10,26–28 . Patients with PDAs originating from the descending aorta, which are accessible via a retrograde approach (i.e., femoral/umbilical), still require care when performing femoral arterial access to avoid femoral artery thrombosis, 9 which occurred in 11% of patients (2/18).…”