Ductal Stenting in Duct-Dependent Pulmonary Circulation: Technical Challenges and Complications in a Resource-Limited Setting

Ductal Stenting in Duct-Dependent Pulmonary Circulation: Technical Challenges and Complications in a Resource-Limited Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ductal Stenting in Duct-Dependent Pulmonary Circulation: Technical Challenges and Complications in a Resource-Limited Setting Andaleeb Ara, Tanzeela Khan, Khurram Akhtar, Nadeem Sadiq, Intisar Ul Haq, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4829123/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To examine the technical challenges and complications of palliative ductal stenting in patients with duct-dependent pulmonary circulation in a resource limited setting. Methodology: This retrospective study was conducted in Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan covering a period from September 2020 to September 2023. The study was approved by the institutional ethical review board. Data of all patients who underwent ductal stenting for duct-dependent pulmonary circulation during the study period were explored. Demographic data of patients, details of the procedure, the immediate procedural outcome, occurrence of any immediate, and early onset complications, re-intervention procedures, and in-hospital mortality were noted. Statistical package for social sciences version 21 was used for data entry and analysis. Results A total of 52 patients underwent ductal stenting procedure during the study period. Males were 27 (51.9%) and females were 25 (48.1%). Age ranged from 1 day to 1460 days (Mean: 133.2 ± 257.47 days; Median: 60 days). The procedure was successful in 47 (90.4%) cases while it was unsuccessful in 5 (9.6%) cases. Seven (13.5%) patients had to undergo a re-intervention procedure raising the total number of ductal stenting procedures during the study period to 59. All of the re-intervention procedures were done successfully. Complications included stent dislodgement in 1 (1.7%) case, stent fracture in 1 (1.7%) case, stent migration in 2 (3.4%), branch pulmonary artery jailing in 5 (8.5%), and stenosis of the uncovered duct in 5 (8.5%) cases. Overall in-hospital mortality of ductal stenting was 5.1%. Conclusion Ductal stenting makes a reasonable palliative therapy in selected cases of duct-dependent pulmonary circulation. Congenital heart disease Duct-dependent pulmonary circulation Patent ductus arteriosus Stenting Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 INTRODUCTION Congenital heart disease with compromised pulmonary blood flow due to atresia or severe stenosis of the pulmonary outflow results in cyanosis in the neonatal period. If the compromised antegrade pulmonary flow is coupled with inadequate or absent collateralization from the systemic circulation, the entirety of the pulmonary supply depends on the ductus in order to sustain life. New-borns having cardiac defects with ductal dependent pulmonary circulation (DD-PC) are usually kept on intravenous prostaglandins in the early neonatal period for temporarily maintaining the patency of the ductus. 1 Before definitive corrective surgery, interim palliation is achieved with systemic to pulmonary artery shunt. Traditionally, the modified Blalock-Taussig (mBT) shunt has been used palliation for such cardiac defects. 2, 3 Being a Risk Adjustment for Congenital Heart Surgery (RACHS)-4 surgery, this palliative procedure is not without significant mortality, and the technical difficulty involved increases with redo sternotomies in the future. 4 Hence the search for alternative procedures resulted in transcatheter ductal stenting (DS) in 1992. 5, 6 Ductal stenting has been increasingly used as palliative procedure instead of surgery over the past few years. 7 The procedure offers advantage over surgical palliation in terms of fewer procedural complications and lower diuretic use at hospital discharge, shorter hospital stay, and larger and more symmetrical pulmonary artery size. 8 However procedure failure and the chance of re-intervention before the definitive surgery are the possible risks. 9, 10 This study aims at highlighting the potential reasons for procedural failure, reinterventions, complications encountered and how to deal with them. METHODOLOGY This retrospective, descriptive, cross-sectional study was conducted in Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC&NIHD), Rawalpindi, Pakistan. Approval of the institutional ethical review board was obtained (R&D department AFIC/NIHD, Rawalpindi letter number 269/2/R&D/2022/223 dated 25 November 2022). All cases of ductal stenting for DD-PC and any re-intervention procedure done at the institute during a period from September 2020 to September 2023 were included. The initial DS was labelled as primary procedure to differentiate it from the re-intervention procedures. Medical documents and cath-lab data of patients were explored for demographic details including age and gender along with reviewing echocardiography and computed tomography (CT) angiography findings. The details of the DS procedure carried out were also reviewed. Cath data was explored for ductal morphology including the origin and ductal tortuosity index. Depending upon the tortuosity, ducts were classified into three types labelling them as type I (straight), type II (mildly tortuous with 1 turn) and type III (tortuous with > 1 turns) – the so-called ductal tortuosity index. 11, 12 Oxygen saturation before the procedure was noted. Procedure details including vascular approach, and equipment used i.e. short sheaths, stent sizes, guide wires, guide catheters and coronary microcatheters were noted. Generally, before undertaking the procedure the hypoxic and sick neonates were first stabilized. Oral prostaglandin E2 (dinoprostone) 35–65 µg/kg 4 hourly was used (intravenous prostaglandin E1 not being available in our country) in some cases. However, because of non-consistent results, it is not in our institutional protocol for every case of DD-PC. Written informed consent was taken and patients shifted to cardiac cath-lab. Vascular access was obtained according to ductal anatomy as dictated by the primary diagnosis, echocardiography and/or CT angiography. Femoral artery, femoral vein or axillary artery access was used and access secured with 4F or 5F short sheath. 4Fr Judkins Right coronary diagnostic catheter or cut pigtail catheter was used for angiograms in left anterior oblique (LAO) 90° and LAO Cranial views to first delineate the origin, angle of take-off, course, tortuosity, narrowest part of the ductus and branch pulmonary artery (BPA) anatomy. 13 Ductus was crossed with 0.014” Balance Middle Weight (BMW) guide wire and parked deep in either of the pulmonary arteries. In some cases, Grand Slam, Pilot 50, 150 or 200 was used. Diagnostic catheter was then exchanged with 5F guide catheter. Stent diameter was chosen according to weight of the patient and length was chosen so as to cover the whole length of the ductus. 14 Post stenting angiograms were taken. Criteria for procedure success was rising Oxygen saturation (SpO 2) and good flow on fluoroscopy immediately after the procedure, functional stent on post-procedure 2-D echocardiography and continuing good SpO 2 until the patient was discharged from hospital. Hospital record of patients having ductal stenting was explored for occurrence of any immediate (during the procedure), early-onset (post-procedure, in-hospital) and delayed onset (after discharge from the hospital) complications like stent dislodgement, migration, embolization, branch pulmonary artery jailing, vascular or myocardial perforation, acute stent thrombosis, sepsis and delayed onset stenosis of the uncovered duct was noted. Hospital record was also checked for re-intervention procedures of these patients. In-hospital mortality of the procedure was calculated. Data was entered in to statistical package for social sciences version 21. Continuous variables were expressed as mean with standard deviation or mean with range. Categorical values were expressed in number and percentage. RESULTS A total of 52 patients with DD-PC underwent DS during the study period. Among them, 27 (51.9%) were males and 25 (48.1%) were females. Seven (13.5%) had to undergo a reintervention procedure raising the total number of procedures during the study period to 59. The age of the patients ranged from 1 to 1460 days (Mean: 133.2 ± 257.47 days; Median: 60 days). Pre-procedure CT angiography was done in 15 (25.4%) cases including one of the reintervention procedures. Out of the total 59 procedures (primary and re-intervention), six (10.2%) were combined with a secondary procedure, four (6.8%) of them being balloon atrial septostomy (BAS) while in one case (1.7%) right ventricular outflow tract (RVOT) ballooning was done and in another case (1.7%) right pulmonary artery (RPA) stenting was performed (1.7%). Femoral artery was the most common approach used being adopted in 33 (55.9%) cases followed by femoral vein used in 13 (21.05%) cases and axillary artery used in 13 (21.05%) cases. The most frequent site of origin of the duct was the underside of the aortic arch seen in 33 (63.5%) followed by the descending aorta noted in 15 (28.8%). The frequency of the site of vascular access in relation to ductal origin is shown in Table I. Table I: Ductal Origin – Site of vascular access (n = 52) Ductal origin Site of vascular access Total Femoral artery (Retrograde) Femoral vein (Antegrade) Axillary artery Underside of the aortic arch 10 11 12 33 Descending aorta 15 0 0 15 Innominate artery 2 0 0 2 Subclavian artery 1 1 - 2 Total 28 12 12 52 Confluence of pulmonary arteries was noted in 51 (98.8%) while in 1 (1.9%) case non-confluence was observed. Unilateral BPA stenosis at the origin was found in 9 (17.3%) cases. Two (3.8%) case had bilateral BPA stenosis. Out of 52 primary procedures, 47 (90.4%) were successful while in 5 (9.6%) cases the procedure was unsuccessful. The unsuccessful cases included cases of tetralogy of Fallot with pulmonary atresia (TOF-PA), tricuspid atresia with pulmonary atresia (TA-PA), pulmonary atresia with intact ventricular septum (PA-IVS), tricuspid atresia with transposition of great arteries and pulmonary atresia (TA-TGA-PA) and PA-unbalanced ventricles-univentricle heart. Three cases had type I duct morphology while two had tortuous type III ducts. One of these unsuccessful cases, aged 6 days with TA-PA had a fatal outcome in post-cath care due to sepsis. In the remaining four cases ductal ballooning was done instead of ductal stenting and remained uneventful during the hospital stay. Among the successfully stented primary cases, 13 (25%) had some minor or major complication (Fig. 1 ). Two successfully stented cases ended up in fatal outcome in post cath care, one because of sepsis and the other due to pulmonary over-circulation. The seven re-intervention cases had presented at different intervals after the primary procedure ranging from the same day to over one year. In all cases restenting was done without any complications (Table 2). Table II. Reintervention cases (n = 7) No. Disease Date of primary DS Duration after primary DS Cause of reintervention Outcome 1 TA-PA 16.10.2020 7 months, 02 days RPA jailing & stenosis of the uncovered duct Successful 2 Right ventricular rhabdomyoma with functional pulmonary and tricuspid atresia 20.04.2021 17 days Stenosis of the uncovered duct Successful 3 TA-PA, blocked mBT shunt 08.03.2022 01 year, 06 days RPA jailing & stent fracture Successful 4 TA-PA 15.07.2022 01 month, 25 days Stenosis of the uncovered duct Successful 5 TA-TGA-PA 22.07.2022 07 days RPA jailing & stenosis of the uncovered duct Successful 6 TOF-PA 21-02-2023 06 days Stenosis of the uncovered duct Successful 7 TA-PA 18.07.2023 Same day Acute stent thrombosis Successful The most frequently used stent diameters were 4 mm and 5 mm, used in 26 (44.1%) and 13 (22%) cases respectively followed by 4.5 mm and 3.5 mm stents. Mean fluoroscopy time was 28.1 ± 17.5 minutes. Mean pre-procedure SpO 2 was 47.6 ± 12.4% and significantly increased after the procedure with mean post-procedure SpO 2 of 89.5 ± 5.6% (p value < 0.001). Out of 59 ductal stenting procedures, three had a fatal outcome during the hospital stay with in-hospital mortality of 5.1%. All other cases recovered and discharged from hospital with advice to report back for routine follow up. DISCUSSION Ductal stenting has emerged as an attractive alternative to the more invasive mBT shunt. 7 Studies are emerging where successful palliation for DD-PC is being achieved with shorter hospital stay and significantly low mortality. 15, 16 We have been carrying out DS in our set-up as a palliative measure in cases of DD-PC for the last few years. Systemic to pulmonary artery shunts are not performed routinely in our setup providing a platform for this less invasive alternative to grow. The present study outlines our experience with this procedure over the past two years. We explored the hospital record of our patients for the success of DS, the development of any immediate, early and delayed onset complications, the need for re-intervention procedures, and in-hospital mortality. Technical challenges related to the procedure were morphology of the ducts (including origin, angle of takeoff and tortuosity) coupled with the limited availability of hardware (smaller sheaths, guide catheters). Ducts arising from the undersurface of arch were easier to negotiate with axillary approach. Antegrade route, in select cases was employed for ducts having more acute angle of takeoff with the part of aorta distal to ductal origin (Fig. 2 ). Ducts in PA-IVS and TA-PA were mostly found to be arising from the descending aorta and had a straighter course and thus the easiest to cross and engage. Many studies have concluded TOF-PA cases to have notoriously difficult for DS with femoral route and thus axillary approach is recommended for TOF-PA and univentricular hearts with PA. 17 18 We tried axillary approach in all such cases but access in those cases was largely altered by the inability to attain axillary approach and thus the alternative route (antegrade or femoral artery) approach was accepted. Difficult ducts, which were crossed with workhorse plasty wires, further presented a challenge when stent was advanced over the wire as crossing wires are not stiff enough to support and track the stent. This issue was tackled by using a coronary microcatheter to exchange the softer wire with stiffer extra support plasty wire, which allowed easier delivery of the stent to the desired site by providing a more stable track. This technique, (in cases where antegrade approach is possible, i.e. in TOF-PA, univentricular hearts) has the advantage of making antegrade delivery of the stent possible thus precluding arterial access and its inherent drawbacks. Moreover, ducts arising from the underside of the arch that would have otherwise required carotid cut down or axillary approach were more conveniently done with the antegrade approach. In occluded ducts, the ductus was recanalized using chronic total occlusion (CTO) wires like pilot 50 and pilot 200 successfully, however, care should be taken with their use as they carry a higher chance of vascular or myocardial perforation. Delivering the stent was achieved with either a 5F Judkins R (JR) guide (4F guides being unavailable in our country) or no guide at all. 5F guide needed a 5F introducer sheath which increased post procedure arterial compromise in neonates. So we switched to sheathless guide technique, where we directly introduced balloon tipped guide into the artery hence precluding the need for up sizing the introducer sheath. In a few cases of axillary approach, stent delivery was easily achieved by just advancing the short sheath with the dilator to the point of interest. This technique reduced a step (i.e. introducing the guide) and any accidental wire displacements associated with it. Ducts with acute take off in the direction opposite to the diagnostic catheter had to be engaged with cut pigtail catheter. These ducts were usually the ones arising from the underside of distal transverse arch which were being approached retrogradely by the femoral artery approach. Although the easier route would have been the axillary approach in such cases, but failure to gain axillary access determined the final approach. The bevel angle of cut pigtail depends on the nature of ductal looping. Ducts with a circular loop could be easily crossed with an un-cut pigtail or bevel pointing backwards, conversely ducts with an opposite turn required the bevel pointing forwards (Fig. 3 ). We had one patient having non-confluent pulmonary arteries in addition to pulmonary atresia. The patient underwent DS to improve the degree of cyanosis and quality of life. Being a resource limited country, procedures such as unifocalization and recruitment of collateral vessels are not possible and hence these patients aren’t subjected to any surgical procedure here. 19 Ductal stenting in this case resulted in marked improvement in the patient’s condition. The pulmonary artery supplied by the ductus was stented, leaving the contralateral lung as such, supplied by aorto-pulmonary collaterals. The role of CT angiography prior to DS is of importance as highlighted by previous studies. 20, 21 We only subjected patients to CT angiography on case to case basis, if the echocardiography windows were inadequate with ambiguity of the findings. 11 Stenosis of BPA has been considered a no-go area in the past but subsequent studies have shown growing experience with such cases. 10 We had one case of bifurcation stenting with left pulmonary artery (LPA) stenosis and hypoplastic RPA, who had undergone DS along with bilateral branch pulmonary artery ballooning. The patient had RPA jailing and presented with stenosis of the uncovered duct 7 months after the primary procedure. Bifurcation stenting was done establishing good flow to BPAs (Fig. 4 ). However, bifurcation stenting is a time consuming and technically difficult procedure and crashing patients who present a do or die situation can be better palliated with DS only instead of bifurcation stenting thus ensuring pulmonary flow albeit unequal. Rescuing the patients till the time they are suitable to undergo cavopulmonary shunt +/- pulmonary artery plasty is the main aim in our institute. Expertise in bifurcation stenting in collaboration with adult coronary interventional cardiologists perhaps needs to be developed. Complications, re-intervention and in-hospital mortality: Ductal stenting is not without the risk of complications. Immediate complications include those related to the access site, ductal spasm or dissection, BPAs dissection, vascular or perforation, stent dislodgement or migration, BPA jailing leading to obstruction, and acute stent thrombosis. Later, stenosis of the uncovered duct and pseudoaneurysm or occlusion of the access site vessel might develop. 22 We encountered stent dislodgement, migration, BPA jailing and stenosis of the uncovered and part of the duct resulting in re-intervention procedures in four cases. a). Stent dislodgement: Ducts with tortuous acute bends do not only present a challenge to engage and cross with wires, but tracking the coronary stent through it (especially those with stenosis at the insertion site or at any site on the ductus) is also particularly challenging. We encountered a case of complete atrioventricular septal defect with pulmonary atresia (cAVSD-PA), along with dextrocardia and right sided aortic arch. The patient had a short type I ductus arising from the undersurface of the arch with tight insertion site stenosis where the coronary stent dislodged off the balloon before it could be positioned. The stent was successfully snared into the short sheath and stenting repeated after ductal preparation (equivalent of coronary lesion preparation) with serial ballooning. This allowed smooth transit of the stent through the stenotic part (Fig. 5 ). We recommend ductal preparation in cases where significant stenosis is encountered. b). Stent migration: Insufficiently constricted ductus should also be steered clear of. Past studies have also shown that a ductus with narrowest diameter of more than or equal to 2.5 mm in neonates should not be stented as there is a high chance of stent embolization/ migration. 14 We had a case of PA-IVS, four days old baby with Pierre Robin sequence, desaturated with SpO 2 of 76%. The ductus had a wide ampulla measuring 5 mm with narrowing at insertion site of 2.7 mm. A 4 mm stent was chosen with a plan to balloon the ampulla portion with a 5 mm balloon so as to abut the stent with the wall properly, proximal optimization technique (POT) equivalent of coronary intervention. But after stent deployment when the balloon was tried to track along the wire, the stent migrated further into the main pulmonary artery (MPA), which was brought back to its position by partial balloon inflation and pulling back the stent which resulted in breakage/bending of the stent with a suboptimal result (Fig. 6 ). Another case of stent migration was due to inadvertent deployment of a short stent distal to stenotic part of the ductus. It is therefore recommended to keep a pull at the stent balloon during deployment as it tends to slip distally. c). Branch pulmonary artery jailing: Branch pulmonary artery jailing is a rare but important complication of ductal stenting occurring more often in cases with BPA stenosis at the origin. 23 Prabhu et al has found the incidence of BPA jailing to be 20.6%. 22 We had four cases (11.4%) of BPAs jailing with two of them developing stenosis of the uncovered part later on (Fig. 7 ). These two cases subsequently had a reintervention procedure. d). Stent failure with ductal stenosis: Ductal tissue has the propensity to constrict and fibrose. 24 The re-intervention cases were primarily those, where proximal uncovered ampulla had developed stenosis due to constriction. There was no thrombus within the stent but angiograms revealed sluggish flow through the stent due to proximal obstruction caused by narrowed lumen. We had four such cases, one of them having a right ventricular rhabdomyoma with functional pulmonary and tricuspid atresia in which BAS had been done along with ductal stenting (Fig. 8 ). 25 Two of them had origin stenosis of BPAs and had ended up in BPA jailing. All four cases were tackled by recrossing and restenting the ductus such that both stents overlapped and the uncovered part was covered. This signifies the importance of covering the entire length of the ductus during the primary procedure in order to avoid future stenosis of the uncovered part. e). In-hospital mortality Total in-hospital mortality in our study was 5.1% which corresponded with a previous study. 8 Furthermore, in our study, none of the deaths was directly attributed to the procedure related complications. Two ward deaths were attributed to nosocomial infections and sepsis and one was due to pulmonary over-circulation. LIMITATIONS The study represents a retrospective insight into a single center experience limited by a lack of long term follow up. Multi-center prospective studies with prolonged follow up are expected to provide more insight in to the immediate, early and delayed onset complications, the final outcome and mortality. CONCLUSION With a good success rate and a shorter hospital stay, DS makes a reasonable palliative therapy in selected cases of duct-dependent pulmonary circulation especially in countries where intensive cardiac surgical care is limited. Declarations CONFLICT OF INTEREST The authors have no relevant financial or non-financial conflicting interests to disclose. Author Contribution A. Ara: Conception and design of the work; the acquisition, analysis, and interpretation of data for the work; manuscript writingT. Khan: Working on figures, data analysis, manuscript writingK. Akhtar: The acquisition, analysis, and interpretation of data for the work; manuscript writingN. 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Initial results and medium-term follow-up of stent implantation of patent ductus arteriosus in duct-dependent pulmonary circulation. J Am Coll Cardiol. 2004;44(2):438-45. Wespi R, Callegari A, Quandt D, Logoteta J, von Rhein M, Kretschmar O, et al. Favourable Short-to Mid-Term Outcome after PDA-Stenting in Duct-Dependent Pulmonary Circulation. Int J Environ Res Public Health. 2022;19(19):12794. Ara A, Akhtar K, Mahmood A, Imtiaz S, Akbar H, Sadiq N. Cardiac rhabdomyoma with severe right ventricular outflow tract obstruction palliated with ductal stenting – a case report. Pak Armed Forces Med J. 2021;71(Suppl-2):S425-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4829123","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344791151,"identity":"48c7526e-1b3b-475f-a6d7-9017e55639b6","order_by":0,"name":"Andaleeb Ara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYHACA4aEChs5fhAzoYBYLQ/OpBlLNoC0GBCphfFh2+HEDQcg2gkD/tnNGz8kAG0xPr868cMDAwZ5frED+LVI3DlWLAHyi9mNt5slgA4znDk7gYA1N3IMJEC2mN04uwGkJcHgNgEt8jdyjH8kAv2yecbZzT+I0mJwI8dMAqRlA3/vNuJsMbyRVmYBcpjEDd5tFgkGEoT9IncjefPNH6Co7D8LZsjzSxPQggASYJUSxCoHAf4DpKgeBaNgFIyCkQQAWUJLT1KvUnoAAAAASUVORK5CYII=","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":true,"prefix":"","firstName":"Andaleeb","middleName":"","lastName":"Ara","suffix":""},{"id":344791152,"identity":"2d2dd37d-1513-4e91-bcae-d5ce710c67f8","order_by":1,"name":"Tanzeela Khan","email":"","orcid":"","institution":"Hayatabad Medical Complex","correspondingAuthor":false,"prefix":"","firstName":"Tanzeela","middleName":"","lastName":"Khan","suffix":""},{"id":344791153,"identity":"716d18ab-51c8-48e1-8a54-fa31965fa28d","order_by":2,"name":"Khurram Akhtar","email":"","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":false,"prefix":"","firstName":"Khurram","middleName":"","lastName":"Akhtar","suffix":""},{"id":344791154,"identity":"08cef456-56b9-4ea9-997b-51497c9ca356","order_by":3,"name":"Nadeem Sadiq","email":"","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":false,"prefix":"","firstName":"Nadeem","middleName":"","lastName":"Sadiq","suffix":""},{"id":344791155,"identity":"bc192dd9-2f0f-4497-ab8d-09526625a4ad","order_by":4,"name":"Intisar Ul Haq","email":"","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":false,"prefix":"","firstName":"Intisar","middleName":"Ul","lastName":"Haq","suffix":""},{"id":344791156,"identity":"94c340fe-6a04-4577-b5ac-f8bdb4b854be","order_by":5,"name":"Kaleem Ahmad","email":"","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":false,"prefix":"","firstName":"Kaleem","middleName":"","lastName":"Ahmad","suffix":""},{"id":344791157,"identity":"987a9b22-ba02-42d6-8e50-ad5eb6a0e2b6","order_by":6,"name":"Saima Rafique","email":"","orcid":"","institution":"Armed Forces Institute of Cardiology (AFIC) \u0026 National Institute of Heart Diseases (NIHD)","correspondingAuthor":false,"prefix":"","firstName":"Saima","middleName":"","lastName":"Rafique","suffix":""}],"badges":[],"createdAt":"2024-07-30 13:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4829123/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4829123/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64005944,"identity":"160eae6f-2b31-4a17-8540-50e50d06a208","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20373,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDuctal stenting from 2020 to 2023\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/81c26094eaa976455f744e9a.png"},{"id":64005945,"identity":"55ed657a-7416-46c8-a993-a0d9f1b0cfdb","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":211877,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDS through antegrade approach. \u003c/strong\u003eA)\u003cstrong\u003e \u003c/strong\u003eAntegrade aortogram in LAO 30° cranial CRA 10° view in a patient with TOF-PA with type I ductus arising from the underside of the arch. Workhorse guidewire (0.014”) has been exchanged with extra support wire using coronary microcatheter. B) Retrograde aortogram in LAO 60 view in the same patient after ductal stenting.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/a2776a773b00a929d7d00726.png"},{"id":64005946,"identity":"efd07cdd-2cb6-4128-8d39-26256fa13025","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":24047,"visible":true,"origin":"","legend":"\u003cp\u003eA. Cut pig-tail with bevel pointing backwards following the ductal loop depicted in (a) circular loop ductus. B. Cut pig tail with bevel pointing forwards to direct the plasty wire through ducts with an opposite turn as depicted in (b).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/d225c1008b168a9eded3ec1b.png"},{"id":64005950,"identity":"9c5bb685-80b7-4fc1-986f-8bddcebee087","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":630219,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBifurcation stenting in a case of TA-PA:\u003c/strong\u003e A) LAO 30°, CRA 20°. Previous ductal stent (white arrow) at the insertion point at LPA. Note the marked RPA origin stenosis and hypoplasia. Note the duct is approached by left axillary artery. B) Anteroposterior (AP) view showing two angioplasty (0.014”) wires parked in LPA and RPA after crossing the previous stent through the true lumen. C) AP view with a second stent (white block arrow) in RPA and a third stent (black arrow) at the bifurcation. The stent 1 (white arrow) was re-crossed and stent 1 and stent 3 ballooned simultaneously. D) AP view showing successful bifurcation stenting with RPA stenosis relieved and good flow bilaterally to branch pulmonary arteries.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/d110214c79cdb1904ab6942a.png"},{"id":64005947,"identity":"12b4818f-5494-4a1d-8d46-dcb4d41437dd","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1169274,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStent dislodgement in a patient with cAVSD-PA with dextrocardia and right sided aortic arch.\u003c/strong\u003e A) Angiogram done through the axillary approach showing a relatively short and straight ductus (type I) with tight insertion stenosis. B) Stent dislodgment after trying to advance the stent through the tight stenosis. Notice the stent distal to balloon markers. C) Stent snared directly into the short sheath after removing the bare balloon. D) Ductal preparation, equivalent of coronary lesion preparation. Stenotic part of the ductus serially ballooned with 2.5 mm and E) 4 mm non-compliant coronary balloons before stenting. F) Angiogram showing good flow through the well-placed ductal stent.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/6c7f5a128d74b196f946d63f.png"},{"id":64006405,"identity":"f160de81-32f7-40ec-9b4a-2c56b491da5d","added_by":"auto","created_at":"2024-09-04 21:50:49","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":494748,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStent migration. A) \u003c/strong\u003eDescending aortogram in LAO 45° with 4F JR catheter showing insufficiently constricted ductus. B) Position of the stent immediately after deployment. C) Notice the forward migration of the stent when a higher size balloon was used for proximal optimization. D) Stent bent at right angle after it was pulled back to its primary location with partial balloon inflation.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/7400ef3a939ebf297a2f84bc.png"},{"id":64007326,"identity":"e873e958-8a36-4053-a163-94db0383331f","added_by":"auto","created_at":"2024-09-04 21:58:49","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":242127,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBranch pulmonary artery jailing. \u003c/strong\u003eA)\u003cstrong\u003e \u003c/strong\u003eDuctal angiogram in LAO 15° CRA 20° view via the antegrade approach in a patient with TA-PA and a blocked mBT shunt showing severe insertion point narrowing and RPA origin stenosis.\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/a82d8f97ee7de1e9571b62a1.png"},{"id":64005951,"identity":"929a954c-852f-4f22-9813-54a7ec6bc35e","added_by":"auto","created_at":"2024-09-04 21:42:49","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":210456,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStenosis of the uncovered part of the ductus. \u003c/strong\u003eA)\u003cstrong\u003e \u003c/strong\u003eDescending aortogram in LAO 90°, 17 days post ductal stenting, of a patient with DD-PCdue to right ventricular rhabdomyoma obstructing the RVOT who presented with worsening cyanosis. Notice the first unobstructed stent (blue box) with proximal narrowing of the uncovered ductus. B) Stent in stent. First stent crossed with BMW wire and another stent positioned so as to keep the stenotic part in the middle and to cover the entire ampulla. C) Post stenting angiogram showing relief of the obstruction.\u003c/p\u003e","description":"","filename":"Figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/b657c9fd5187f6c76acfb272.png"},{"id":75794410,"identity":"3d74690d-2d61-4da7-8baf-9b1c29079164","added_by":"auto","created_at":"2025-02-08 13:16:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4549280,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4829123/v1/692fb555-bf2d-443e-96c6-1f41d52cf591.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ductal Stenting in Duct-Dependent Pulmonary Circulation: Technical Challenges and Complications in a Resource-Limited Setting","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCongenital heart disease with compromised pulmonary blood flow due to atresia or severe stenosis of the pulmonary outflow results in cyanosis in the neonatal period. If the compromised antegrade pulmonary flow is coupled with inadequate or absent collateralization from the systemic circulation, the entirety of the pulmonary supply depends on the ductus in order to sustain life.\u003c/p\u003e \u003cp\u003eNew-borns having cardiac defects with ductal dependent pulmonary circulation (DD-PC) are usually kept on intravenous prostaglandins in the early neonatal period for temporarily maintaining the patency of the ductus.\u003csup\u003e1\u003c/sup\u003e Before definitive corrective surgery, interim palliation is achieved with systemic to pulmonary artery shunt. Traditionally, the modified Blalock-Taussig (mBT) shunt has been used palliation for such cardiac defects.\u003csup\u003e2, 3\u003c/sup\u003e Being a Risk Adjustment for Congenital Heart Surgery (RACHS)-4 surgery, this palliative procedure is not without significant mortality, and the technical difficulty involved increases with redo sternotomies in the future.\u003csup\u003e4\u003c/sup\u003e Hence the search for alternative procedures resulted in transcatheter ductal stenting (DS) in 1992.\u003csup\u003e5, 6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDuctal stenting has been increasingly used as palliative procedure instead of surgery over the past few years.\u003csup\u003e7\u003c/sup\u003e The procedure offers advantage over surgical palliation in terms of fewer procedural complications and lower diuretic use at hospital discharge, shorter hospital stay, and larger and more symmetrical pulmonary artery size.\u003csup\u003e8\u003c/sup\u003e However procedure failure and the chance of re-intervention before the definitive surgery are the possible risks.\u003csup\u003e9, 10\u003c/sup\u003e This study aims at highlighting the potential reasons for procedural failure, reinterventions, complications encountered and how to deal with them.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis retrospective, descriptive, cross-sectional study was conducted in Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC\u0026amp;NIHD), Rawalpindi, Pakistan. Approval of the institutional ethical review board was obtained (R\u0026amp;D department AFIC/NIHD, Rawalpindi letter number 269/2/R\u0026amp;D/2022/223 dated 25 November 2022). All cases of ductal stenting for DD-PC and any re-intervention procedure done at the institute during a period from September 2020 to September 2023 were included. The initial DS was labelled as primary procedure to differentiate it from the re-intervention procedures. Medical documents and cath-lab data of patients were explored for demographic details including age and gender along with reviewing echocardiography and computed tomography (CT) angiography findings. The details of the DS procedure carried out were also reviewed. Cath data was explored for ductal morphology including the origin and ductal tortuosity index. Depending upon the tortuosity, ducts were classified into three types labelling them as type I (straight), type II (mildly tortuous with 1 turn) and type III (tortuous with \u0026gt;\u0026thinsp;1 turns) \u0026ndash; the so-called ductal tortuosity index.\u003csup\u003e11, 12\u003c/sup\u003e Oxygen saturation before the procedure was noted. Procedure details including vascular approach, and equipment used i.e. short sheaths, stent sizes, guide wires, guide catheters and coronary microcatheters were noted. Generally, before undertaking the procedure the hypoxic and sick neonates were first stabilized. Oral prostaglandin E2 (dinoprostone) 35\u0026ndash;65 \u0026micro;g/kg 4 hourly was used (intravenous prostaglandin E1 not being available in our country) in some cases. However, because of non-consistent results, it is not in our institutional protocol for every case of DD-PC. Written informed consent was taken and patients shifted to cardiac cath-lab. Vascular access was obtained according to ductal anatomy as dictated by the primary diagnosis, echocardiography and/or CT angiography. Femoral artery, femoral vein or axillary artery access was used and access secured with 4F or 5F short sheath. 4Fr Judkins Right coronary diagnostic catheter or cut pigtail catheter was used for angiograms in left anterior oblique (LAO) 90\u0026deg; and LAO Cranial views to first delineate the origin, angle of take-off, course, tortuosity, narrowest part of the ductus and branch pulmonary artery (BPA) anatomy.\u003csup\u003e13\u003c/sup\u003e Ductus was crossed with 0.014\u0026rdquo; Balance Middle Weight (BMW) guide wire and parked deep in either of the pulmonary arteries. In some cases, Grand Slam, Pilot 50, 150 or 200 was used. Diagnostic catheter was then exchanged with 5F guide catheter. Stent diameter was chosen according to weight of the patient and length was chosen so as to cover the whole length of the ductus.\u003csup\u003e14\u003c/sup\u003e Post stenting angiograms were taken. Criteria for procedure success was rising Oxygen saturation (SpO\u003csub\u003e2)\u003c/sub\u003e and good flow on fluoroscopy immediately after the procedure, functional stent on post-procedure 2-D echocardiography and continuing good SpO\u003csub\u003e2\u003c/sub\u003e until the patient was discharged from hospital. Hospital record of patients having ductal stenting was explored for occurrence of any immediate (during the procedure), early-onset (post-procedure, in-hospital) and delayed onset (after discharge from the hospital) complications like stent dislodgement, migration, embolization, branch pulmonary artery jailing, vascular or myocardial perforation, acute stent thrombosis, sepsis and delayed onset stenosis of the uncovered duct was noted. Hospital record was also checked for re-intervention procedures of these patients. In-hospital mortality of the procedure was calculated.\u003c/p\u003e \u003cp\u003eData was entered in to statistical package for social sciences version 21. Continuous variables were expressed as mean with standard deviation or mean with range. Categorical values were expressed in number and percentage.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 52 patients with DD-PC underwent DS during the study period. Among them, 27 (51.9%) were males and 25 (48.1%) were females. Seven (13.5%) had to undergo a reintervention procedure raising the total number of procedures during the study period to 59. The age of the patients ranged from 1 to 1460 days (Mean: 133.2\u0026thinsp;\u0026plusmn;\u0026thinsp;257.47 days; Median: 60 days). Pre-procedure CT angiography was done in 15 (25.4%) cases including one of the reintervention procedures. Out of the total 59 procedures (primary and re-intervention), six (10.2%) were combined with a secondary procedure, four (6.8%) of them being balloon atrial septostomy (BAS) while in one case (1.7%) right ventricular outflow tract (RVOT) ballooning was done and in another case (1.7%) right pulmonary artery (RPA) stenting was performed (1.7%). Femoral artery was the most common approach used being adopted in 33 (55.9%) cases followed by femoral vein used in 13 (21.05%) cases and axillary artery used in 13 (21.05%) cases.\u003c/p\u003e \u003cp\u003eThe most frequent site of origin of the duct was the underside of the aortic arch seen in 33 (63.5%) followed by the descending aorta noted in 15 (28.8%). The frequency of the site of vascular access in relation to ductal origin is shown in Table I.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I: Ductal Origin \u0026ndash; Site of vascular access (n\u0026thinsp;=\u0026thinsp;52)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDuctal origin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSite of vascular access\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemoral artery \u003cem\u003e(Retrograde)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemoral vein \u003cem\u003e(Antegrade)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAxillary artery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderside of the aortic arch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescending aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInnominate artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubclavian artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConfluence of pulmonary arteries was noted in 51 (98.8%) while in 1 (1.9%) case non-confluence was observed. Unilateral BPA stenosis at the origin was found in 9 (17.3%) cases. Two (3.8%) case had bilateral BPA stenosis.\u003c/p\u003e \u003cp\u003eOut of 52 primary procedures, 47 (90.4%) were successful while in 5 (9.6%) cases the procedure was unsuccessful. The unsuccessful cases included cases of tetralogy of Fallot with pulmonary atresia (TOF-PA), tricuspid atresia with pulmonary atresia (TA-PA), pulmonary atresia with intact ventricular septum (PA-IVS), tricuspid atresia with transposition of great arteries and pulmonary atresia (TA-TGA-PA) and PA-unbalanced ventricles-univentricle heart. Three cases had type I duct morphology while two had tortuous type III ducts. One of these unsuccessful cases, aged 6 days with TA-PA had a fatal outcome in post-cath care due to sepsis. In the remaining four cases ductal ballooning was done instead of ductal stenting and remained uneventful during the hospital stay.\u003c/p\u003e \u003cp\u003eAmong the successfully stented primary cases, 13 (25%) had some minor or major complication (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Two successfully stented cases ended up in fatal outcome in post cath care, one because of sepsis and the other due to pulmonary over-circulation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe seven re-intervention cases had presented at different intervals after the primary procedure ranging from the same day to over one year. In all cases restenting was done without any complications (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II. Reintervention cases (n\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDate of primary DS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuration after primary DS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCause of reintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTA-PA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.10.2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 months, 02 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRPA jailing \u0026amp; stenosis of the uncovered duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight ventricular rhabdomyoma with functional pulmonary and tricuspid atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.04.2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStenosis of the uncovered duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTA-PA, blocked mBT shunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e08.03.2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e01 year, 06 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRPA jailing \u0026amp; stent fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTA-PA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.07.2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e01 month, 25 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStenosis of the uncovered duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTA-TGA-PA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.07.2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e07 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRPA jailing \u0026amp; stenosis of the uncovered duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTOF-PA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21-02-2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e06 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStenosis of the uncovered duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTA-PA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.07.2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSame day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcute stent thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most frequently used stent diameters were 4 mm and 5 mm, used in 26 (44.1%) and 13 (22%) cases respectively followed by 4.5 mm and 3.5 mm stents. Mean fluoroscopy time was 28.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5 minutes. Mean pre-procedure SpO\u003csub\u003e2\u003c/sub\u003e was 47.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4% and significantly increased after the procedure with mean post-procedure SpO\u003csub\u003e2\u003c/sub\u003e of 89.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6% (p value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Out of 59 ductal stenting procedures, three had a fatal outcome during the hospital stay with in-hospital mortality of 5.1%. All other cases recovered and discharged from hospital with advice to report back for routine follow up.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eDuctal stenting has emerged as an attractive alternative to the more invasive mBT shunt.\u003csup\u003e7\u003c/sup\u003e Studies are emerging where successful palliation for DD-PC is being achieved with shorter hospital stay and significantly low mortality.\u003csup\u003e15, 16\u003c/sup\u003e We have been carrying out DS in our set-up as a palliative measure in cases of DD-PC for the last few years. Systemic to pulmonary artery shunts are not performed routinely in our setup providing a platform for this less invasive alternative to grow. The present study outlines our experience with this procedure over the past two years. We explored the hospital record of our patients for the success of DS, the development of any immediate, early and delayed onset complications, the need for re-intervention procedures, and in-hospital mortality.\u003c/p\u003e \u003cp\u003eTechnical challenges related to the procedure were morphology of the ducts (including origin, angle of takeoff and tortuosity) coupled with the limited availability of hardware (smaller sheaths, guide catheters). Ducts arising from the undersurface of arch were easier to negotiate with axillary approach. Antegrade route, in select cases was employed for ducts having more acute angle of takeoff with the part of aorta distal to ductal origin (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Ducts in PA-IVS and TA-PA were mostly found to be arising from the descending aorta and had a straighter course and thus the easiest to cross and engage. Many studies have concluded TOF-PA cases to have notoriously difficult for DS with femoral route and thus axillary approach is recommended for TOF-PA and univentricular hearts with PA.\u003csup\u003e17 18\u003c/sup\u003e We tried axillary approach in all such cases but access in those cases was largely altered by the inability to attain axillary approach and thus the alternative route (antegrade or femoral artery) approach was accepted.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDifficult ducts, which were crossed with workhorse plasty wires, further presented a challenge when stent was advanced over the wire as crossing wires are not stiff enough to support and track the stent. This issue was tackled by using a coronary microcatheter to exchange the softer wire with stiffer extra support plasty wire, which allowed easier delivery of the stent to the desired site by providing a more stable track. This technique, (in cases where antegrade approach is possible, i.e. in TOF-PA, univentricular hearts) has the advantage of making antegrade delivery of the stent possible thus precluding arterial access and its inherent drawbacks. Moreover, ducts arising from the underside of the arch that would have otherwise required carotid cut down or axillary approach were more conveniently done with the antegrade approach. In occluded ducts, the ductus was recanalized using chronic total occlusion (CTO) wires like pilot 50 and pilot 200 successfully, however, care should be taken with their use as they carry a higher chance of vascular or myocardial perforation.\u003c/p\u003e \u003cp\u003eDelivering the stent was achieved with either a 5F Judkins R (JR) guide \u003cem\u003e(4F guides being unavailable in our country)\u003c/em\u003e or no guide at all. 5F guide needed a 5F introducer sheath which increased post procedure arterial compromise in neonates. So we switched to sheathless guide technique, where we directly introduced balloon tipped guide into the artery hence precluding the need for up sizing the introducer sheath. In a few cases of axillary approach, stent delivery was easily achieved by just advancing the short sheath with the dilator to the point of interest. This technique reduced a step (i.e. introducing the guide) and any accidental wire displacements associated with it.\u003c/p\u003e \u003cp\u003eDucts with acute take off in the direction opposite to the diagnostic catheter had to be engaged with cut pigtail catheter. These ducts were usually the ones arising from the underside of distal transverse arch which were being approached retrogradely by the femoral artery approach. Although the easier route would have been the axillary approach in such cases, but failure to gain axillary access determined the final approach. The bevel angle of cut pigtail depends on the nature of ductal looping. Ducts with a circular loop could be easily crossed with an un-cut pigtail or bevel pointing backwards, conversely ducts with an opposite turn required the bevel pointing forwards (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe had one patient having non-confluent pulmonary arteries in addition to pulmonary atresia. The patient underwent DS to improve the degree of cyanosis and quality of life. Being a resource limited country, procedures such as unifocalization and recruitment of collateral vessels are not possible and hence these patients aren’t subjected to any surgical procedure here.\u003csup\u003e19\u003c/sup\u003e Ductal stenting in this case resulted in marked improvement in the patient’s condition. The pulmonary artery supplied by the ductus was stented, leaving the contralateral lung as such, supplied by aorto-pulmonary collaterals.\u003c/p\u003e \u003cp\u003eThe role of CT angiography prior to DS is of importance as highlighted by previous studies.\u003csup\u003e20, 21\u003c/sup\u003e We only subjected patients to CT angiography on case to case basis, if the echocardiography windows were inadequate with ambiguity of the findings.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStenosis of BPA has been considered a no-go area in the past but subsequent studies have shown growing experience with such cases.\u003csup\u003e10\u003c/sup\u003e We had one case of bifurcation stenting with left pulmonary artery (LPA) stenosis and hypoplastic RPA, who had undergone DS along with bilateral branch pulmonary artery ballooning. The patient had RPA jailing and presented with stenosis of the uncovered duct 7 months after the primary procedure. Bifurcation stenting was done establishing good flow to BPAs (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, bifurcation stenting is a time consuming and technically difficult procedure and crashing patients who present a do or die situation can be better palliated with DS only instead of bifurcation stenting thus ensuring pulmonary flow albeit unequal. Rescuing the patients till the time they are suitable to undergo cavopulmonary shunt +/- pulmonary artery plasty is the main aim in our institute. Expertise in bifurcation stenting in collaboration with adult coronary interventional cardiologists perhaps needs to be developed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eComplications, re-intervention and in-hospital mortality:\u003c/h2\u003e \u003cp\u003eDuctal stenting is not without the risk of complications. Immediate complications include those related to the access site, ductal spasm or dissection, BPAs dissection, vascular or perforation, stent dislodgement or migration, BPA jailing leading to obstruction, and acute stent thrombosis. Later, stenosis of the uncovered duct and pseudoaneurysm or occlusion of the access site vessel might develop.\u003csup\u003e22\u003c/sup\u003e We encountered stent dislodgement, migration, BPA jailing and stenosis of the uncovered and part of the duct resulting in re-intervention procedures in four cases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ea). Stent dislodgement:\u003c/h2\u003e \u003cp\u003eDucts with tortuous acute bends do not only present a challenge to engage and cross with wires, but tracking the coronary stent through it (especially those with stenosis at the insertion site or at any site on the ductus) is also particularly challenging. We encountered a case of complete atrioventricular septal defect with pulmonary atresia (cAVSD-PA), along with dextrocardia and right sided aortic arch. The patient had a short type I ductus arising from the undersurface of the arch with tight insertion site stenosis where the coronary stent dislodged off the balloon before it could be positioned. The stent was successfully snared into the short sheath and stenting repeated after ductal preparation (equivalent of coronary lesion preparation) with serial ballooning. This allowed smooth transit of the stent through the stenotic part (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). We recommend ductal preparation in cases where significant stenosis is encountered.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eb). Stent migration:\u003c/h2\u003e \u003cp\u003eInsufficiently constricted ductus should also be steered clear of. Past studies have also shown that a ductus with narrowest diameter of more than or equal to 2.5 mm in neonates should not be stented as there is a high chance of stent embolization/ migration.\u003csup\u003e14\u003c/sup\u003e We had a case of PA-IVS, four days old baby with Pierre Robin sequence, desaturated with SpO\u003csub\u003e2\u003c/sub\u003e of 76%. The ductus had a wide ampulla measuring 5 mm with narrowing at insertion site of 2.7 mm. A 4 mm stent was chosen with a plan to balloon the ampulla portion with a 5 mm balloon so as to abut the stent with the wall properly, proximal optimization technique (POT) equivalent of coronary intervention. But after stent deployment when the balloon was tried to track along the wire, the stent migrated further into the main pulmonary artery (MPA), which was brought back to its position by partial balloon inflation and pulling back the stent which resulted in breakage/bending of the stent with a suboptimal result (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Another case of stent migration was due to inadvertent deployment of a short stent distal to stenotic part of the ductus. It is therefore recommended to keep a pull at the stent balloon during deployment as it tends to slip distally.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ec). Branch pulmonary artery jailing:\u003c/h2\u003e \u003cp\u003eBranch pulmonary artery jailing is a rare but important complication of ductal stenting occurring more often in cases with BPA stenosis at the origin.\u003csup\u003e23\u003c/sup\u003e Prabhu et al has found the incidence of BPA jailing to be 20.6%.\u003csup\u003e22\u003c/sup\u003e We had four cases (11.4%) of BPAs jailing with two of them developing stenosis of the uncovered part later on (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). These two cases subsequently had a reintervention procedure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ed). Stent failure with ductal stenosis:\u003c/h2\u003e \u003cp\u003eDuctal tissue has the propensity to constrict and fibrose.\u003csup\u003e24\u003c/sup\u003e The re-intervention cases were primarily those, where proximal uncovered ampulla had developed stenosis due to constriction. There was no thrombus within the stent but angiograms revealed sluggish flow through the stent due to proximal obstruction caused by narrowed lumen. We had four such cases, one of them having a right ventricular rhabdomyoma with functional pulmonary and tricuspid atresia in which BAS had been done along with ductal stenting (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003csup\u003e25\u003c/sup\u003e Two of them had origin stenosis of BPAs and had ended up in BPA jailing. All four cases were tackled by recrossing and restenting the ductus such that both stents overlapped and the uncovered part was covered. This signifies the importance of covering the entire length of the ductus during the primary procedure in order to avoid future stenosis of the uncovered part.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003ee). In-hospital mortality\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eTotal in-hospital mortality in our study was 5.1% which corresponded with a previous study.\u003csup\u003e8\u003c/sup\u003e Furthermore, in our study, none of the deaths was directly attributed to the procedure related complications. Two ward deaths were attributed to nosocomial infections and sepsis and one was due to pulmonary over-circulation.\u003c/p\u003e \u003c/div\u003e "},{"header":"LIMITATIONS","content":"\u003cp\u003eThe study represents a retrospective insight into a single center experience limited by a lack of long term follow up. Multi-center prospective studies with prolonged follow up are expected to provide more insight in to the immediate, early and delayed onset complications, the final outcome and mortality.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWith a good success rate and a shorter hospital stay, DS makes a reasonable palliative therapy in selected cases of duct-dependent pulmonary circulation especially in countries where intensive cardiac surgical care is limited.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST\u003c/h2\u003e \u003cp\u003eThe authors have no relevant financial or non-financial conflicting interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA. Ara: Conception and design of the work; the acquisition, analysis, and interpretation of data for the work; manuscript writingT. Khan: Working on figures, data analysis, manuscript writingK. Akhtar: The acquisition, analysis, and interpretation of data for the work; manuscript writingN. Sadiq: Data analysis, manuscript writingI. U. Haq: Data analysis, manuscript writingK. Ahmad: Data analysis, manuscript writingS. Rafique: Data analysis, manuscript writing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCucerea M, Simon M, Moldovan E, Ungureanu M, Marian R, Suciu L. Congenital heart disease requiring maintenance of ductus arteriosus in critically ill newborns admitted at a tertiary neonatal intensive care unit. J Crit Care Med. 2016;2(4):185.\u003c/li\u003e\n\u003cli\u003eBlalock A, Taussig HB. The surgical treatment of malformations of the heart: in which there is pulmonary stenosis or pulmonary atresia. JAMA. 1945;128(3):189-202.\u003c/li\u003e\n\u003cli\u003ede Leval MR, McKay R, Jones M, Stark J, Macartney FJ. Modified Blalock-Taussig shunt: use of subclavian artery orifice as flow regulator in prosthetic systemic-pulmonary artery shunts. J Thorac Cardiovasc Surg. 1981;81(1):112-9.\u003c/li\u003e\n\u003cli\u003eAbdelMassih AF, Menshawey R, Menshawey E, El-Maghraby AE, Sabry AO, Kamel A, et al. Blalock-Taussig Shunt versus Ductal Stent in the Palliation of Duct Dependent Pulmonary Circulation; A Systematic Review and Metanalysis. Curr Probl Cardiol. 2021:100885.\u003c/li\u003e\n\u003cli\u003eWilliams JA, Bansal AK, Kim BJ, Nwakanma LU, Patel ND, Seth AK, et al. Two thousand Blalock-Taussig shunts: a six-decade experience. Ann Thorac Surg. 2007;84(6):2070-5.\u003c/li\u003e\n\u003cli\u003eGibbs JL, Rothman M, Rees M, Parsons J, Blackburn M, Ruiz C. Stenting of the arterial duct: a new approach to palliation for pulmonary atresia. Heart. 1992;67(3):240-5.\u003c/li\u003e\n\u003cli\u003eRatnayaka K, Nageotte SJ, Moore JW, Guyon PW, Bhandari K, Weber RL, et al. Patent ductus arteriosus stenting for all ductal-dependent cyanotic infants: waning use of blalock-taussig shunts. Circ Cardiovasc Interv. 2021;14(3):e009520.\u003c/li\u003e\n\u003cli\u003eGlatz AC, Petit CJ, Goldstein BH, Kelleman MS, McCracken CE, McDonnell A, et al. Comparison between patent ductus arteriosus stent and modified Blalock-Taussig shunt as palliation for infants with ductal-dependent pulmonary blood flow: insights from the congenital catheterization research collaborative. Circulation. 2018;137(6):589-601.\u003c/li\u003e\n\u003cli\u003eBentham JR, Zava NK, Harrison WJ, Shauq A, Kalantre A, Derrick G, et al. Duct stenting versus modified Blalock-Taussig shunt in neonates with duct-dependent pulmonary blood flow: associations with clinical outcomes in a multicenter national study. Circulation. 2018;137(6):581-8.\u003c/li\u003e\n\u003cli\u003eAggarwal V, Petit CJ, Glatz AC, Goldstein BH, Qureshi AM. Stenting of the ductus arteriosus for ductal‐dependent pulmonary blood flow\u0026mdash;current techniques and procedural considerations. Congenit Heart Dis. 2019;14(1):110-5.\u003c/li\u003e\n\u003cli\u003eQureshi AM, Goldstein BH, Glatz AC, Agrawal H, Aggarwal V, Ligon RA, et al. Classification scheme for ductal morphology in cyanotic patients with ductal dependent pulmonary blood flow and association with outcomes of patent ductus arteriosus stenting. Catheter Cardiovasc Interv. 2019;93(5):933-43.\u003c/li\u003e\n\u003cli\u003eJadhav SP, Aggarwal V, Masand PM, Diaz E, Zhang W, Qureshi AM. Correlation of ductus arteriosus length and morphology between computed tomographic angiography and catheter angiography and their relation to ductal stent length. Pediatr Radiol. 2020;50(6):800-9.\u003c/li\u003e\n\u003cli\u003eQureshi AM, Caldarone CA, Romano JC, Chai PJ, Mascio CE, Glatz AC, et al. Comparison of management strategies for neonates with symptomatic tetralogy of Fallot and weight\u0026lt; 2.5 kg. J Thorac Cardiovasc Surg. 2021.\u003c/li\u003e\n\u003cli\u003eAlwi M. Stenting the ductus arteriosus: case selection, technique and possible complications. Ann Pediatr Cardiol. 2008;1(1):38.\u003c/li\u003e\n\u003cli\u003eAlsagheir A, Koziarz A, Makhdoum A, Contreras J, Alraddadi H, Abdalla T, et al. Duct stenting versus modified Blalock\u0026ndash;Taussig shunt in neonates and infants with duct-dependent pulmonary blood flow: A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2021;161(2):379-90. e8.\u003c/li\u003e\n\u003cli\u003eBoucek DM, Qureshi AM, Goldstein BH, Petit CJ, Glatz AC. Blalock‐Taussig shunt versus patent ductus arteriosus stent as first palliation for ductal‐dependent pulmonary circulation lesions: a review of the literature. Congenit Heart Dis. 2019;14(1):105-9.\u003c/li\u003e\n\u003cli\u003eRehman R, Marhisham MC, Alwi M. Stenting the complex patent ductus arteriosus in tetralogy of Fallot with pulmonary atresia: challenges and outcomes. Future Cardiol. 2018;14(1):55-73.\u003c/li\u003e\n\u003cli\u003ePolat TB. Stenting the vertical ductus arteriosus via axillary artery access using \u0026ldquo;wire‐target\u0026rdquo; technique. Congenit Heart Dis. 2017;12(6):800-7.\u003c/li\u003e\n\u003cli\u003eBarron DJ, Kutty RS, Stickley J, St\u0026uuml;mper O, Botha P, Khan NE, et al. Unifocalization cannot rely exclusively on native pulmonary arteries: the importance of recruitment of major aortopulmonary collaterals in 249 cases. Eur J Cardiothorac Surg. 2019;56(4):679-87.\u003c/li\u003e\n\u003cli\u003eChamberlain RC, Ezekian JE, Sturgeon GM, Barker PC, Hill KD, Fleming GA. Preprocedural three‐dimensional planning aids in transcatheter ductal stent placement: a single‐center experience. Catheter Cardiovasc Interv. 2020;95(6):1141-8.\u003c/li\u003e\n\u003cli\u003eArar Y, Dimas VV, Nugent AW, Hussain T, Kasraie N, Reddy SRV, et al. Pre-procedural CT imaging aids neonatal PDA stenting for ductal-dependent pulmonary blood flow with reduction in overall procedural morbidity. Cardiol Young. 2022;32(9):1401-6.\u003c/li\u003e\n\u003cli\u003ePrabhu S, Joshi A, Mehra S, Shetty R, Murthy K, Ramachandra P, et al. Branch Pulmonary Artery Jailing During Patent Ductus Arteriosus Stenting: Recruitment and Immediate Outcomes. World J Pediatr Congenit Heart Surg. 2021;12(3):320-30.\u003c/li\u003e\n\u003cli\u003eAlwi M, Choo K, Latiff HA, Kandavello G, Samion H, Mulyadi M. Initial results and medium-term follow-up of stent implantation of patent ductus arteriosus in duct-dependent pulmonary circulation. J Am Coll Cardiol. 2004;44(2):438-45.\u003c/li\u003e\n\u003cli\u003eWespi R, Callegari A, Quandt D, Logoteta J, von Rhein M, Kretschmar O, et al. Favourable Short-to Mid-Term Outcome after PDA-Stenting in Duct-Dependent Pulmonary Circulation. Int J Environ Res Public Health. 2022;19(19):12794.\u003c/li\u003e\n\u003cli\u003eAra A, Akhtar K, Mahmood A, Imtiaz S, Akbar H, Sadiq N. Cardiac rhabdomyoma with severe right ventricular outflow tract obstruction palliated with ductal stenting \u0026ndash; a case report. Pak Armed Forces Med J. 2021;71(Suppl-2):S425-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Congenital heart disease, Duct-dependent pulmonary circulation, Patent ductus arteriosus, Stenting","lastPublishedDoi":"10.21203/rs.3.rs-4829123/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4829123/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo examine the technical challenges and complications of palliative ductal stenting in patients with duct-dependent pulmonary circulation in a resource limited setting.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eThis retrospective study was conducted in Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan covering a period from September 2020 to September 2023. The study was approved by the institutional ethical review board. Data of all patients who underwent ductal stenting for duct-dependent pulmonary circulation during the study period were explored. Demographic data of patients, details of the procedure, the immediate procedural outcome, occurrence of any immediate, and early onset complications, re-intervention procedures, and in-hospital mortality were noted. Statistical package for social sciences version 21 was used for data entry and analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 52 patients underwent ductal stenting procedure during the study period. Males were 27 (51.9%) and females were 25 (48.1%). Age ranged from 1 day to 1460 days (Mean: 133.2\u0026thinsp;\u0026plusmn;\u0026thinsp;257.47 days; Median: 60 days). The procedure was successful in 47 (90.4%) cases while it was unsuccessful in 5 (9.6%) cases. Seven (13.5%) patients had to undergo a re-intervention procedure raising the total number of ductal stenting procedures during the study period to 59. All of the re-intervention procedures were done successfully. Complications included stent dislodgement in 1 (1.7%) case, stent fracture in 1 (1.7%) case, stent migration in 2 (3.4%), branch pulmonary artery jailing in 5 (8.5%), and stenosis of the uncovered duct in 5 (8.5%) cases. Overall in-hospital mortality of ductal stenting was 5.1%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDuctal stenting makes a reasonable palliative therapy in selected cases of duct-dependent pulmonary circulation.\u003c/p\u003e","manuscriptTitle":"Ductal Stenting in Duct-Dependent Pulmonary Circulation: Technical Challenges and Complications in a Resource-Limited Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 21:42:44","doi":"10.21203/rs.3.rs-4829123/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1f6668f8-7045-4853-b95a-68c58e435468","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-08T13:08:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-04 21:42:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4829123","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4829123","identity":"rs-4829123","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}