Editorial Comment

The Arterial Duct. . . the NaturalSubstitute for a Surgical Shunt?

Victor Lucas,* MD, FSCAI

Department of Pediatric Cardiology andInterventional Pediatric Cardiology, OchsnerClinic Foundation, New Orleans, Louisiana

In this episode of the CCI journal, Santoro et al.report their extensive experience with percutaneousductus stent placement for the management of ductus-dependent pulmonary blood flow in newborns as analternative to surgical shunt creation.

In this report, the feasibility of percutaneous ductusstent placement in tiny infants weighing less than2.5 kg is specifically examined. The data presentedsupport the feasibility of the percutaneous approach inthe tiny infants, albeit at the ‘‘cost’’ of slightly higherradiation exposure, a higher rate of initial clinical con-gestive heart failure, and increased need for repeatinterventions before definitive surgical correction ascompared to ductus stent procedure in larger newborns.The procedural risk profile reported seems to beacceptable when compared with historical surgical dataand ductus stent data for larger infants.

The authors are to be commended for their detailedreporting of the technical variables. Notably, stopping

prostaglandin infusion for several hours before the

procedure seems important to allow ductus constriction

to facilitate stent retention and to avoid the need for

excessively large stents. Bolus and continuous heparin

infusion for 24 hr coupled with early antiplatelet

treatment effectively avoids acute stent thrombosis.

Accurate measurement of the ductus diameter and

complete stent coverage of the ductus are emphasized.

‘‘Unconventional’’ vascular access is an integral part

of this procedure, as ductus stent placement in tiny

infants from a femoral arterial approach is not always

straightforward.

The increased need for reintervention before defini-

tive surgical palliation in this group should be anti-

cipated, if oversized stents are avoided. This practice

should compare favorably to the placement of

relatively oversized surgical shunts in this group, but

this issue deserves further examination over time. An

obvious advantage of ductus stent placement compared

to surgical shunt is the opportunity to tailor the pulmo-

nary blood flow by graded ductus stent dilation to the

patient’s size over time.

The late deaths unrelated to the ductus stent proce-

dure observed in the tiny infant group highlight the

very high-risk nature of this patient population. Ductus

stent placement in tiny infants with ductus-dependent

pulmonary blood flow is a viable treatment option.

Conflict of interest: Nothing to report.

*Correspondence to: Dr. Victor Lucas, 1315 Jefferson Highway,

New Orleans, LA 70121. E-mail: vlucas@ochsner.org

Received 31 August 2011; Revision accepted 13 September 2011

DOI 10.1002/ccd.23376

Published online 21 October 2011 in Wiley Online Library

(wileyonlinelibrary.com).

' 2011 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 78:686 (2011)