Arterial Duct Stenting in Congenital Heart Disease with Duct-Dependent Pulmonary Circulation

Background: Despite current trends toward early primary repair, surgical systemic-to-pulmonary artery shunt is still an invaluable palliative option in some high-risk patients with congenital heart disease and duct-dependent pulmonary blood flow. However, maintaining arterial duct patency by stent implantation has been proposed as an effective alternative to surgical palliation in neonates who are unsuitable for primary repair or in whom there is anticipated spontaneous improvement of oxygen saturation as the pulmonary vascular resistance decreases. Recent advances in technology has made arterial duct stenting a safe and feasible tool for short-term palliation of newborns and young infants with this pathophysiologic arrangement. This option might be even more advisable in low-weight newborns, who are at higher risk for surgical palliation or repair and in whom repeat stent dilatations could be effective in tailoring the pulmonary flow to the patient's growth. This paper highlights history, methodology and results of this innovative and minimally-invasive palliative option. Methods and Results: Following duct morphology evaluation, the stent is chosen to completely cover the entire ductal length and is dilated to about 75% of the proposed surgical shunt. The procedure can be performed from arterial or venous approach and is successfully completed in the vast majority of cases. Procedural failure mainly depends on ductal tortuosity, typically found in complex conotruncal anomalies such as tetralogy of Fallot or pulmonary atresia with ventricular septal defect. The morbidity rate ranges from 8 to 11% and mainly consists in stent embolization or thrombosis as well as vascular access injury. The mid-term fate of the stented duct is spontaneous, slow and progressive closure within a few months. However, the stented arterial duct promotes similar and more balanced pulmonary artery growth than surgical shunt over a mid-term follow-up. Conclusions: Arterial duct stenting is a technically feasible, safe and effective palliation in congenital heart disease with duct-dependent pulmonary circulation. The stented arterial duct is less durable than conventional surgical shunt but is highly effective in promoting global and balanced pulmonary artery growth.