Transcatheter Closure of Patent Ductus Arteriosus in Infants With Weight Under 1,500 Grams

Abstract

Persistent patent ductus arteriosus (PDA) is very common in preterm infants, especially in extremely preterm infants. Despite significant advances in management of these vulnerable infants, there has been no consensus on management of PDA-when should we treat, who should we treat, how should we treat and in fact there is no agreement on how we should define a hemodynamically significant PDA. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) remains the first line of therapy with moderate success rate in closing the PDA. Paracetamol has been reported to be a safe and equally effective medical therapy for closure of PDA. However, additional studies on its long-term safety and efficacy in extremely low birth weight infants are needed before paracetamol can be recommended as standard treatment for a PDA in preterm infants. Surgical ligation of PDA is not without an increased risk of mortality and co-morbidities. Recently, there has been a significant interest in percutaneous transcatheter closure of PDA in preterm infants, including extremely low birth weight infants. Transcatheter PDA closure in preterm ELBW infants is technically feasible with high PDA occlusion success rates and acceptable complication rates as compared to surgical ligation. Many centers have reported promising early-and mid-term follow-up results. However, they need to be further tested in the prospective well-designed studies and randomized controlled trials comparing the results and outcomes of this technique with current treatment strategies including medical treatment before they can be used as the new standard of care for PDA closure in extremely low birth weight infants.

Consensus Guidelines for the Prevention and Management of Periprocedural Complications of Transcatheter Patent Ductus Arteriosus Closure with the Amplatzer Piccolo Occluder in Extremely Low Birth Weight Infants

“…Device embolization is a known complication of transcatheter PDA closure but is of particular concern in ELBW infants as surgical retrieval may be technically challenging and associated with a high degree of morbidity due to patient size. [4,11,12]. Most instances of device embolization occur either during the procedure or immediately post procedure into one of the pulmonary artery branches and can be safely retrieved via a transcatheter approach.…”

“…In recent years, there has been a growing interest in utilizing transcatheter patent ductus arteriosus (PDA) closure in extremely low birth weight (ELBW) infants as a less invasive alternative to surgical ligation and a more effective treatment option compared to medical therapy [1][2][3]. With increased procedural experience a modified technique for transcatheter PDA closure was developed to minimize adverse events in ELBW infants [4][5][6]. The modified implant technique avoids arterial access and exclusively utilizes a transvenous antegrade approach guided by fluoroscopy, venous angiography, and transthoracic echocardiography (TTE) with placement of the entire device within an intraductal position to avoid aortic and pulmonary artery protrusion [7,8].…”

The Patent Ductus Arteriosus in Adults with Special Focus on Role of CT

“…Complication of surgical ligation includes bleeding, recurrent laryngeal nerve palsy, infection, chylothorax, and pneumothorax. However, technical advancements today permit even some large PDAs to be treated by percutaneous closure [ 22 , 23 ] with a lower morbidity rate and lesser postprocedural pain compared to surgery.…”

“…Since then, there have been remarkable advances in the technique for transcatheter closure of PDAs [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ], and evolution is continuing with the following aims for the closure device: (1) making the device with material compatible with MRI; (2) conforming it to the full spectrum of PDA sizes and shapes; (3) permitting it to be safely delivered with a sheath of small diameter; (4) allowing free retrievability of the device; (5) crafting a device that will permanently occlude the PDA. Closure by an interventional occluder device is the primary therapeutic choice in infants, children, and adults with a small or moderate size symptomatic PDA [ 1 , 11 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ].…”

“…Coronary angiography has been used as the standard method of planimetry to assess the PDA [ 23 ]. However, angiography has limitations in evaluating the precise minimal and maximal diameter and length of PDA because of the two-dimensional nature of angiography.…”