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J Thorac Cardiovasc Surg 2008;135:699-701
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Division of Cardiac Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, & Vascular Diseases, Capital Medical University, Beijing, China
b Division of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, & Vascular Diseases, Capital Medical University, Beijing, China
c Division of Vascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, & Vascular Diseases, Capital Medical University, Beijing, China
Received for publication September 3, 2007; accepted for publication November 26, 2007. * Address for reprints: Yong-Qiang Lai, MD, Division of Cardiac Surgery, Beijing Anzhen Hospital, 36 Wuluju Chaoyang District, Beijing, China, 100029. (Email: yongqianglai{at}yahoo.com).
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Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative treatment for adult patent ductus arteriosus (PDA) in recent years.1
We report here our preliminary experience in treating adult PDA with stent–grafts.
From September 2005 to March 2007, a total of 4 patients with a large PDA and pulmonary hypertension underwent TEVAR. All patients had exertional dyspnea. Transthoracic echocardiography, computed tomographic angiography, and right heart catheterization were conducted before the operation. All patients had severe pulmonary hypertension. Indications for stent–graft implantation were as follows: (1) adult patient with large PDA, (2) no other congenital cardiac defects, (3) no right-to-left shunt, (4) adequate landing zone (arch diameter <35 mm), and (5) adequate access route. The study was approved by the institutional review board, and informed consent was obtained. Clinical data are summarized in
Table 1.
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Brachial and pulmonary arterial pressures were monitored. Different arteries were used as access routes. The right common femoral artery was used in 2 patients. Transperitoneal exposure of the abdominal aorta was performed in 1 patient. The common iliac artery was mobilized through the postperitoneal approach by a left oblique hypogastric incision in 1 patient. Tapered stent–grafts (Grikin Advanced Materials Co, Ltd, Beijing, China) were used. The left subclavian artery (LSCA) was covered simultaneously in all patients.
Stent-grafts were successfully implanted in all patients. Mean pulmonary arterial pressure decreased from 65.8 ± 8.4 mm Hg to 40.5 ± 7.6 mm Hg (P < .05). Postoperative course was uneventful. Complete occlusion of the PDA was achieved immediately after stent-graft implantation in 3 patients (
Figure 1). A cuff was added in 1 patient during the procedure, but there was still trivial left-to-right shunt. Before discharge, however, the shunt could no longer be seen with transthoracic echocardiography and computed tomographic angiography. There were no complications (eg, left arm claudication or vertebrobasilar insufficiency) either after the operation or during follow-up.
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Because of the fragility of the aorta and aneurysmal change of the ductus, the surgical closure (whether through a left thoracotomy or sternotomy) of PDA in adult patients carries a high risk. When severe pulmonary hypertension is present, the risk of surgical repair of PDA increases dramatically, especially when the transpulmonary closure technique is used with hypothermic circulatory arrest.2 Transcatheter closure with umbrella or spring coil has proved to be an effective and safe treatment. When a large PDA and severe pulmonary hypertension are present, however, transcatheter closure can be problematic. The most serious complication is the dislodgment of the umbrella.3
Use of TEVAR to occlude the aortic opening of a PDA is a reasonable alternative for the correction of this anomaly. The procedure is less invasive than is open-chest surgery. Moreover, it is more secure than an umbrella. Our early results are encouraging.
Because of the large left-to-right shunt at the level of descending aorta and less blood going to the lower body, the diameter of the common femoral artery was small in our patients. Preoperative evaluation of femoral and iliac arteries with ultrasonography is important. If the common femoral artery is small (diameter <7 mm), then the common iliac artery or even abdominal aorta should be considered. The common iliac artery can be exposed through a postperitoneal approach with a left oblique hypogastric incision.
A sufficient proximal landing zone is essential for stent–graft landing and PDA sealing. The LSCA was sacrificed in all of our patients because of its proximity to the PDA. Because we considered this procedure relatively safe in light of our previous experience,4 no preoperative tests were performed to demonstrate its safety. There were no complications related to the occlusion of the LSCA, either after the operation or during follow-up. A stent–graft with fenestration or a side arm might preserve the blood flow to the LSCA5; however, such stent–grafts are not yet available for purchase.
Early results of TEVAR of PDA are encouraging. As such, TEVAR may be a therapeutic alternative for adult patients with large PDA and pulmonary hypertension. Long-term follow-ups are needed.
References
This article has been cited by other articles:
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  G. Kataoka, Y. Nakamura, O. Tagusari, and M. Nagashima Adult Patent Ductus Arteriosus Closure With a Pedicled Pulmonary Arterial Patch Ann. Thorac. Surg., September 1, 2010; 90(3): e46 - e48. [Abstract] [Full Text] [PDF]
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