PDA Stenting With Versus Without Pre-Procedural 3D Reconstruction: Impact on Radiation Exposure and Procedural Outcomes

PDA Stenting With Versus Without Pre-Procedural 3D Reconstruction: Impact on Radiation Exposure and Procedural Outcomes | 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 PDA Stenting With Versus Without Pre-Procedural 3D Reconstruction: Impact on Radiation Exposure and Procedural Outcomes Marjan Hesari, Mitsuhiro Jo, Kamel Shibbani, Danica Peterson, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9228884/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Managing patients with patent ductus arteriosus (PDA) and complex anatomical features, such as tortuosity and branching anomalies, remains a challenge in interventional cardiology. Recent advances in three-dimensional (3D) reconstruction and quantitative analysis of ductal anatomy have shown promise in improving procedural outcomes. This study evaluates the utility of 3D reconstruction in pre-procedural planning for PDA stenting. Methods This retrospective, single-center study included patients who underwent PDA stenting or modified Blalock-Taussig-Thomas from January 2010 to March 2025. Pre-procedural 3D reconstruction was performed for a subset of patients, allowing for detailed analysis of ductal tortuosity, vessel diameter, and other anatomic variables. Procedural outcomes, including radiation exposure, procedure time, and the need for reintervention, were compared between the 3D and non-3D-guided groups. Results A total of 46 patients were included in the analysis, with 26 having preprocedural 3D-guided planning. The 3D group demonstrated significantly lower mean Air Kerma (50.4 vs 108 mGy, p = 0.0149) and dose area product (186 vs 344 cGy·cm², p = 0.0295). Case length and fluoroscopy time were shorter but not statistically significant. There was a trend toward fewer reinterventions in the 3D group (10% vs 18%, p = 0.06). Stratification by tortuosity type revealed that 3D planning was particularly beneficial in cases with high tortuosity. Conclusion Preprocedural 3D reconstruction is a valuable tool in planning PDA interventions with a high success rate and significantly lower radiation exposure. These findings support the incorporation of 3D modeling into routine clinical practice for complex PDA cases, potentially improving procedural efficiency and patient outcomes. PDA 3D reconstruction Patent ductus arteriosus PDA stenting radiation exposure Figures Figure 1 Figure 2 Figure 3 Introduction Neonates with ductal-dependent pulmonary blood flow (DDPBF) require timely intervention to maintain adequate pulmonary circulation. Although the modified Blalock–Taussig–Thomas shunt (mBTTS) has historically been the standard palliative approach, patent ductus arteriosus (PDA) stenting has emerged as an effective alternative, offering favorable outcomes such as reduced morbidity, shorter intensive care unit stays, and more balanced pulmonary artery growth, albeit with an increased need for reintervention ( 1 – 6 ). Despite these advantages, PDA stenting can be challenging in cases with complex ductal anatomy, such as reverse orientation or high tortuosity, contributing to a procedural failure rate of up to 16%( 7 ). Ductal morphology plays a critical role in procedural planning and success, influencing the risk of branch pulmonary artery jailing, reintervention rates, and the selection of vascular access. Accordingly, optimizing pre-procedural planning is essential to improve procedural outcomes ( 8 – 10 ). Three-dimensional (3D) reconstruction techniques have been increasingly utilized to enhance the visualization of complex congenital cardiac anatomy( 11 – 17 ).High-resolution models derived from computed tomography (CT) imaging enable detailed assessment of spatial relationships and ductal characteristics, potentially facilitating more precise procedural planning ( 18 – 21 ).However, data directly evaluating the clinical impact of 3D reconstruction in PDA stenting remains limited. In this study, we compare outcomes of PDA stenting performed with versus without pre-procedural 3D reconstruction, with a focus on procedural efficiency, radiation exposure, and reintervention rates. Methods This retrospective, single-center study was conducted at Rady Children’s Hospital, San Diego, and approved by the University of California, San Diego (UCSD) Human Research Protections Program. The requirement for informed consent was waived. All patients with DDPBF who underwent PDA stenting at our institution between January 2, 2013, and March 25, 2025, were retrospectively reviewed. A significant shift in institutional management occurred after 2017, transitioning to a universal PDA stenting strategy for all infants with DDPBF requiring palliation with a higher propensity toward preprocedural CT. In 2018, the institution also implemented 3D reconstruction capabilities. Patients were stratified into two categories: 3D reconstruction before intervention and no 3D reconstruction prior to intervention (3D reconstruction was performed post hoc where cross-sectional images were available. Nineteen patients were in the “non-3D group,” and twenty-seven patients were in the “3D group”; analysis started after the universal PDA stenting strategy was implemented. All cases were discussed and approved during multidisciplinary team conferences before intervention. Demographics, clinical characteristics, procedural details, and follow-up data were obtained from electronic medical records and securely stored in REDCap. Segmentation and reconstruction of 3D models of patient anatomy were conducted using Mimics Innovation Suite (Version 25, Materialize, Leuven, Belgium). Patient images were imported and manually segmented based on intensity values (i.e., intensity value thresholding) to produce masks of the cardiac anatomy and airway. The following blood volumes were segmented from the main cardiac structure: aortic arch with outlet vessels, patent ductus arteriosus, and the pulmonary artery; major aortopulmonary collateral arteries (MAPCAs) were also reconstructed if present. Segmented masks were converted to 3D meshes and exported into Geomagic Wrap (3D Systems, Rock Hill, SC) for further processing and refinement. Noise removal and component refinement/labeling of each distinct cardiac segment were performed. Data was re-imported into Mimics to check for accuracy. Outputs from the reconstruction process in Mimics are shown in Fig. 1 (A). A centerline was constructed with a spline in Mimics along the aorta, PDA, and pulmonary arteries, shown in Fig. 1 (B). The distance along the centerline was used to determine the full length of the PDA and tortuosity along the PDA was calculated in Eq. 1. The tortuosity was also categorized based on the scheme outlined by Qureshi et al., as shown in Fig. 2 ( 22 ). The path between the outlet vessel and the proximal end of the PDA was qualitatively characterized through a spline tool, shown in Fig. 3 . (Eq. 1) $$\:\text{T}\text{o}\text{r}\text{t}\text{u}\text{o}\text{s}\text{i}\text{t}\text{y}\:\text{I}\text{n}\text{d}\text{e}\text{x}\:=\:\frac{\text{L}{-\text{L}}_{\text{s}}}{\text{L}}\:\:$$ $$\:{\text{L}}_{\text{c}}:\text{f}\text{u}\text{l}\text{l}\:\text{l}\text{e}\text{n}\text{g}\text{t}\text{h}\:\text{o}\text{f}\:\text{P}\text{D}\text{A}$$ $$\:{\text{L}}_{\text{s}}:\:\text{l}\text{e}\text{n}\text{g}\text{t}\text{h}\:\text{P}\text{D}\text{A}\:\text{m}\text{e}\text{a}\text{s}\text{u}\text{e}\text{d}\:\text{a}\text{s}\:\text{a}\:\text{s}\text{t}\text{r}\text{a}\text{i}\text{g}\text{h}\text{t}\:\text{l}\text{i}\text{n}\text{e}\:\text{f}\text{r}\text{o}\text{m}\:\text{o}\text{r}\text{i}\text{g}\text{i}\text{n}\:\text{t}\text{o}\:\text{i}\text{n}\text{s}\text{e}\text{r}\text{t}\text{i}\text{o}\text{n}$$ Study outcomes included quantitative and qualitative characterization of the ductus arteriosus as well as procedural metrics such as fluoroscopy time, contrast volume, and radiation dose. Reintervention rates were also evaluated. Reintervention was defined as any catheter-based procedure on the PDA stent, such as redilation or additional stent placement. Surgical procedures to enhance pulmonary blood flow, including shunt placement or early second-stage operations, were also classified as reinterventions. Baseline descriptive statistics were calculated for the study population. Continuous variables were summarized as mean ± standard deviation and median [interquartile range]. Categorical variables were presented as frequencies and percentages. Between-group comparisons (3D modeling reconstruction preprocedural vs. no 3D modeling reconstruction) were performed using a t-test for continuous variables and Fisher’s exact test for categorical variables. Odds ratios (OR) with 95% confidence intervals were calculated for categorical comparisons. A p-value < 0.05 was considered statistically significant. Results Patient characteristic A total of 46 patients with DDPBF were included in the study, of whom 27 underwent preprocedural 3D reconstruction (“3D groups”) modeling, and 19 did not (“non-3D group”). Baseline demographic and clinical characteristics were comparable between groups. Median birth weight was similar between the 3D group (3.26 kg [IQR: 2.75–3.64]) and the non-3D group (3.00 kg [IQR: 2.76–3.30]). Age and weight at the time of the first intervention were also comparable. The incidence of prematurity and genetic syndromes did not differ significantly between cohorts. Baseline anatomical diagnoses and procedural characteristics are summarized in Table 1 . Single-ventricle physiology with pulmonary atresia predominated in the 3D modeling group, whereas PA with intact ventricular septum (PA/IVS) was the most frequent diagnosis in the non-3D cohort. Vascular access strategies differed between groups, with carotid and axillary access more commonly utilized in the 3D group, while femoral access predominated in the non-3D cohort. PDA morphology, classified by tortuosity index, was comparable between groups, with Type III ducts representing the most prevalent morphology in both cohorts. Table 1. Patients Characteristics No 3D (n=19) 3D (n=27) Sex (F) 10 (52%) 12 (44%) Birth Weight 3 (2.76-3.30) 3.26 (2.75-3.64) Age at 1 st intervention 8 (4.5-11) 9 (7-23) Weight at 1 st intervention 3.33 (3.12-3.75) 3.35 (3.07-3.94) Anatomic Diagnosis* PA/IVS TOF or DORV with PA or PS TGA with PA Single ventricle with PA (DILV, unbalanced AVC, TA) Heterotaxy with PA (TAPVR, Other 8 4 2 2 1 2 7 4 6 6 3 1 Gestational age, weeks 39 (37/0.5-39/2.5) 38/6 (36/6.5-39/3) Prematurity 4 (21%) 6 (22%) Genetic Syndrome 3 (15%) 5 (18%) Access Femoral UAC Axillary Carotid 7 (37%) 5 (26%) 6 (32%) 1 (5%) 3 (11%) 5 (19%) 9 (33%) 10 (37%) PDA Type I II III 5 (26%) 6 (32%) 8 (42%) 5 (19%) 10 (37%) 12 (44%) * PA/IVS: Pulmonary atresia with Intact Ventricular septum, TOF: Tetralogy of Fallot, DORV: Double outlet Right Ventricular, TGA: Transposition of Great Arteries, PA: Pulmonary Atresia, DILV: Double Inlet left Ventricular, Tetralogy of Fallot, TA: Tricuspid Atresia, TAPVR: Total Anomalous Pulmonary Venous Return, Other: Hypoplastic Left heart Syndrome, Ebstein Anomaly, Situs Solitus. Outcomes Among all patients, those who underwent 3D reconstruction prior to intervention demonstrated improved procedural characteristics, particularly in terms of radiation exposure. Mean Air Kerma was significantly lower in the 3D group compared to those without prior 3D modeling (50.4 mGy vs 108 mGy, p = 0.0149), with a moderate effect size (0.36). Similarly, mean dose area product (DAP) was reduced in the 3D group (186 cGy·cm² vs 344 cGy·cm², p = 0.0295). While mean case length and fluoroscopy time were shorter with 3D modeling, the differences did not reach statistical significance. The need for catheter-based re-intervention prior to definitive surgical repair was also lower in the 3D group (48.1% vs 78.9%), trending toward significance ( p = 0.0644) with an odds ratio of 4.04 (95% CI: 1.06–15.37). (Table 2 ) Table 2 Outcomes by Time of 3D modeling Case Length (min) Did not Have 3D Prior (N = 19) Had 3D Prior (N = 27) P-Value Effect Size/OR (95% C.I.) Mean (SD) 122 (68.5) 91.4 (42.6) 0.0858 0.26 (-0.01, 0.51) Median (Q1-Q3) 131 (76.0-144) 80.0 (60.5–128) Flouro Time (min) Mean (SD) 26.4 (18.9) 19.8 (11.4) 0.2505 0.17 (-0.11, 0.4) Median (Q1-Q3) 23.6 (14.0–31.0) 14.8 (11.8–24.6) Air Kerma (mGy) Mean (SD) 108 (91.0) 50.4 (41.3) 0.0149 0.36 (0.09, 0.62) Median (Q1-Q3) 93.3 (44.3–137) 36.2 (22.8–66.3) DAP (cGy.cm2) Mean (SD) 344 (284) 186 (163) 0.0295 0.32 (0.05, 0.59) Median (Q1-Q3) 297 (147–469) 123 (70.3–222) Re-intervention prior to surgical repair No 4 (21.1%) 14 (51.9%) 0.0644 4.04 (1.06, 15.37) Yes 15 (78.9%) 13 (48.1%) In the subgroup of patients with tortuosity index type II and III, these trends persisted. Air Kerma remained significantly lower in the 3D modeling group (54.4 mGy vs 115 mGy, p = 0.0449), and DAP showed a borderline significant reduction (200 cGy·cm² vs 368 cGy·cm², p = 0.0714). Although differences in procedure duration and fluoroscopy time were not statistically significant in this subgroup. Table 3 Table 3 Outcomes by Time of 3D modeling in Subgroup of Tortuosity Type 2 and 3 Case Length (min) Did not Have 3D Prior (N = 14) Had 3D Prior (N = 22) P-Value Effect Size/OR (95% C.I.) Mean (SD) 124 (74.9) 94.2 (43.4) 0.3066 0.17 (-0.11, 0.4) Median (Q1, Q3) 115 (71.0, 144) 85.0 (65.3, 128) Flouro Time (min) Mean (SD) 27.7 (20.9) 21.0 (12.1) 0.4703 0.12 (-0.18, 0.32) Median (Q1, Q3) 23.3 (11.8, 31.9) 16.7 (12.6, 25.9) Air Kerma (mGy) Mean (SD) 115 (98.7) 54.4 (43.9) 0.0449 0.36 (0.04, 0.64) Median (Q1, Q3) 95.5 (41.4, 130) 37.4 (24.0, 76.3) DAP (cGy.cm2) Mean (SD) 368 (307) 200 (175) 0.0714 0.30 (0.01, 0.6) Median (Q1, Q3) 299 (157, 480) 137 (68.0, 257) Re-intervention Prior to Surgical Repair No 3 (21.4%) 11 (50.0%) 0.16 3.67 (0.79, 16.86) Yes 11 (78.6%) 11 (50.0%) Discussion This study evaluated the impact of pre-procedural 3D modeling on PDA stenting, focusing on radiation exposure, efficiency, and the need for re-intervention. PDA stenting is an evolving procedure, with ongoing efforts to optimize outcomes by reducing complication rates, minimizing reintervention frequency, and enhancing overall procedural effectiveness ( 23 , 24 ). Our findings suggest that the use of 3D modeling prior to intervention is associated with significantly reduced radiation exposure, as evidenced by lower Air Kerma and DAP values. These findings were consistent across the full cohort and within the subgroup of patients with moderate to severe vascular tortuosity (types 2 and 3), indicating that the benefits of 3D modeling may be particularly valuable in anatomically complex cases. When a pre-procedural CT scan has been performed, the subsequent angiogram in the catheterization lab can often be conducted using fluoroscopy alone, without the need for cine angiography. In this context, the goal is not to obtain detailed anatomical imaging but rather a procedural roadmap. Moreover, 3D CT data can be used to determine optimal angiographic angles prior to the procedure. By referencing the 3D reconstruction, the operator can directly position the imaging system in the best angulation—whether RAO cranial, LAO cranial, or another view—without requiring multiple acquisitions to determine the ideal projection. This approach helps reduce the number of angiographic runs, thereby lowering both radiation exposure and contrast use. In addition, while ionizing radiation from both CT and catheter-based procedures carries an associated long-term cancer risk( 25 , 26 ), recent advancements in imaging techniques and scanning protocols have decreased radiation exposure from CT scans, with average effective doses of 1 millisievert (mSv) or less ( 27 , 28 ). While there are no established reference doses for PDA stenting, available data indicate that for infants under one year old, the radiation from chest CT angiography is considerably lower than that from diagnostic catheterization; median effective doses are approximately 0.76 mSv for CT and 13.4 mSv for catheter-based studies ( 26 , 29 ). These findings support the selective use of low-dose pre-procedural CT imaging as a valuable adjunct in procedural planning, offering improvements in efficiency and safety without significantly increasing the overall radiation burden. Our study builds on this evidence by demonstrating that patients who underwent pre-procedural 3D modeling had significantly lower intra-procedural radiation exposure, highlighting the practical impact of this approach in a real-world cohort. PDA stenting has emerged as an alternative to mBTTS, though it does carry a higher risk of reintervention( 4 , 30 ). This is partly since these patients often undergo scheduled interval catheterizations, during which both planned and incidental reinterventions may occur. The increased reintervention rate in the PDA stent group is largely attributable to the initial procedure. However, such reinterventions can be viewed as a potential advantage, as PDA stents act as “adjustable shunts” that can be expanded to accommodate somatic growth. A common reason for early reintervention following PDA stenting is incomplete coverage of the ductus by the initial implant( 31 ). Full ductal coverage can often prevent this complication, even if it results in the stent protruding into the pulmonary artery or the aorta during the initial procedure.( 32 ). Pre-procedural 3D modeling can aid in preventing such complications by providing precise anatomical visualization, allowing for more accurate stent sizing and positioning. Most reinterventions involve stent re-dilation and placement of an additional stent to address restenosis. However, catheter-based approaches are not always sufficient, necessitating surgical revision or shunt placement( 4 , 31 , 33 ). In our cohort, patients who underwent pre-procedural 3D modeling demonstrated a trend toward lower unplanned reintervention rates, nearing statistical significance (p = 0.0644). Although this difference did not reach conventional significance (p < 0.05), the observed trend supports the notion that 3D modeling enhances initial procedural planning and execution, potentially reducing the need for further interventions before definitive surgical repair ( 34 , 35 ). In this study, pre-procedural 3D reconstruction was associated with a significant reduction in radiation exposure and a trend toward improved procedural efficiency and reduced need for reintervention. These findings suggest that enhanced anatomical understanding prior to intervention may facilitate more precise procedural planning, particularly in patients with complex ductal morphology. Given the increasing use of PDA stenting as a primary palliative strategy in ductal-dependent pulmonary blood flow, integration of 3D reconstruction into routine pre-procedural workflows may represent an important step toward improving both procedural safety and outcomes. Future prospective studies with larger cohorts are warranted to further validate these findings and define the role of 3D-guided planning in optimizing interventional strategies in this high-risk population. Limitations This study has several limitations. First, the sample size was relatively small, which may limit the statistical power and generalizability of our findings. Second, Prostaglandin-E1 (PGE-1) is used to keep the ductus arteriosus patent and can be life-saving in neonates with ductal-dependent PBF. 31 Patients with ductal-dependent PBF are often reliant on PGE-1 in ensuring patency and preventing constriction of the PDA prior to PDA stenting. 12 In this patient cohort, all 3D reconstructions of the PDA are of patients who were, at the time, infused with PGE-1. However, several hours prior to stenting, the patient is taken off PGE-1 to prepare for catheterization. As such, there may be a discrepancy in the diameter, tortuosity, straight length, and full length of the reconstructed PDA compared to true PDA measurements at the time of stenting in the catheter lab. Conclusion The use of pre-procedural 3D modeling in PDA stenting appears to offer meaningful clinical benefits, including reduced radiation exposure and a lower likelihood of requiring catheter-based reintervention, particularly in patients with complex ductal anatomy. Declarations Conflict of Interest The authors declare that there are no conflicts of interest related to this study. Ethics statement and patient consent The study was conducted following the research protocols and was approved by the relevant institutional review boards at the University of San Diego. Funding sources This research did not receive funding support from public, commercial, or not-for-profit sectors. Author Contribution D.P. was responsible for data collection. M.H. contributed to data writing analysing the data. J.R. and M.J. performed the visualization. K.S. oversaw data accuracy and provided supervision. H.E. conceived the research idea and supervised the project. Acknowledgment: We would like to express our gratitude to Helen and the Will Webster Foundation for their support of the 3D Innovations Lab at Rady Children's Hospital, San Diego, CA, USA. 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Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 05 May, 2026 Reviews received at journal 01 May, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers agreed at journal 01 Apr, 2026 Reviewers invited by journal 30 Mar, 2026 Editor assigned by journal 26 Mar, 2026 Submission checks completed at journal 26 Mar, 2026 First submitted to journal 25 Mar, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-9228884","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614392061,"identity":"96a60ac1-47cd-4bc6-86fd-e419e4bd3d40","order_by":0,"name":"Marjan Hesari","email":"","orcid":"","institution":"University of California","correspondingAuthor":false,"prefix":"","firstName":"Marjan","middleName":"","lastName":"Hesari","suffix":""},{"id":614392064,"identity":"df5670cc-9b3e-4052-8980-3d29e4c3ad0c","order_by":1,"name":"Mitsuhiro Jo","email":"","orcid":"","institution":"University of California","correspondingAuthor":false,"prefix":"","firstName":"Mitsuhiro","middleName":"","lastName":"Jo","suffix":""},{"id":614392069,"identity":"f97de229-53ef-4ed0-aac3-246051df9b8d","order_by":2,"name":"Kamel Shibbani","email":"","orcid":"","institution":"Rady Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kamel","middleName":"","lastName":"Shibbani","suffix":""},{"id":614392071,"identity":"9a1e2a2b-a46a-4ba7-9c36-60182e7a3286","order_by":3,"name":"Danica Peterson","email":"","orcid":"","institution":"University of California","correspondingAuthor":false,"prefix":"","firstName":"Danica","middleName":"","lastName":"Peterson","suffix":""},{"id":614392075,"identity":"940e7c0f-e270-49b6-80cc-57c5c6ba99f7","order_by":4,"name":"Justin R Ryan","email":"","orcid":"","institution":"Rady Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"R","lastName":"Ryan","suffix":""},{"id":614392077,"identity":"67f207c8-6b57-4e99-a955-2d2c310e3a3d","order_by":5,"name":"Howaida G. El-Said","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACAwYGxgMMDBKM/QwMbERrYQBrmdlAohYGxg0HiNVizr/4wMEfNRaym28kP3vwoYJBnl/sAH4tljOeJRzmOSZhvO1GmrnhjDMMhjNnJxBw2I0zBocZ2CQSt91IMJPmbWNIMLhNUMv5Dwd//JNI3Dwj/RuRWs73MBzgbZNI3CCRQ7QtbAaHefskjGeceVMmOeOMBBF+OX/44cMf3+pk+9vTt0l8qLCR55cmoIVBAqZAAMyQIKAcBPgPoDNGwSgYBaNgFKABAKz0Sn1x2ZEoAAAAAElFTkSuQmCC","orcid":"","institution":"University of California","correspondingAuthor":true,"prefix":"","firstName":"Howaida","middleName":"G.","lastName":"El-Said","suffix":""}],"badges":[],"createdAt":"2026-03-26 03:54:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9228884/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9228884/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105885171,"identity":"6a99f66c-9c03-40b7-a5b9-627bcb8708c1","added_by":"auto","created_at":"2026-04-01 07:25:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139454,"visible":true,"origin":"","legend":"\u003cp\u003e(A) 3D reconstruction of PAs, aorta, PDA, and great vessels reimported into Mimics and color-coded. (B) 3D reconstruction of PAs, aorta, PDA, and great vessels with transparency and centerline rendering.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9228884/v1/7fc99d1a8a4874901921b9f0.png"},{"id":105885210,"identity":"74b59d15-8f12-4d1a-8eb6-b32fd9f3fd1a","added_by":"auto","created_at":"2026-04-01 07:25:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":477939,"visible":true,"origin":"","legend":"\u003cp\u003e(A) 3D reconstruction of type I tortuosity. (B) 3D reconstruction of type II tortuosity. (C) 3D reconstruction of type III tortuosity. Tortuosity was categorized based on the classification scheme outlined in Qureshi et al.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9228884/v1/d057a5205f3f598753dca52a.png"},{"id":105884954,"identity":"d9a8f2a9-35ad-4ed0-a6dd-85eb7cd2414b","added_by":"auto","created_at":"2026-04-01 07:24:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":302880,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Spline measurement between the outlet vessel and PDA with the most direct access and the least tortuosity. Yellow denotes the full distance between the vessel and PDA. Light blue denotes the direct displacement between the vessel and PDA. (B) Spline measurement between the PDA and two different outlet vessels. Tortuosity was measured according to \u003cstrong\u003eEq. 1 \u003c/strong\u003eto determine the outlet vessel with the most direct access to the PDA.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9228884/v1/d999805d01d849dd5bc45e82.png"},{"id":105885921,"identity":"118ccb4b-8e8b-4f1d-b220-2131ed096709","added_by":"auto","created_at":"2026-04-01 07:28:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1708786,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9228884/v1/9532b3c7-f91d-40be-9a20-fb190e18974b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"PDA Stenting With Versus Without Pre-Procedural 3D Reconstruction: Impact on Radiation Exposure and Procedural Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeonates with ductal-dependent pulmonary blood flow (DDPBF) require timely intervention to maintain adequate pulmonary circulation. Although the modified Blalock\u0026ndash;Taussig\u0026ndash;Thomas shunt (mBTTS) has historically been the standard palliative approach, patent ductus arteriosus (PDA) stenting has emerged as an effective alternative, offering favorable outcomes such as reduced morbidity, shorter intensive care unit stays, and more balanced pulmonary artery growth, albeit with an increased need for reintervention (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these advantages, PDA stenting can be challenging in cases with complex ductal anatomy, such as reverse orientation or high tortuosity, contributing to a procedural failure rate of up to 16%(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Ductal morphology plays a critical role in procedural planning and success, influencing the risk of branch pulmonary artery jailing, reintervention rates, and the selection of vascular access. Accordingly, optimizing pre-procedural planning is essential to improve procedural outcomes (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThree-dimensional (3D) reconstruction techniques have been increasingly utilized to enhance the visualization of complex congenital cardiac anatomy(\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).High-resolution models derived from computed tomography (CT) imaging enable detailed assessment of spatial relationships and ductal characteristics, potentially facilitating more precise procedural planning (\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).However, data directly evaluating the clinical impact of 3D reconstruction in PDA stenting remains limited.\u003c/p\u003e \u003cp\u003eIn this study, we compare outcomes of PDA stenting performed with versus without pre-procedural 3D reconstruction, with a focus on procedural efficiency, radiation exposure, and reintervention rates.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This retrospective, single-center study was conducted at Rady Children\u0026rsquo;s Hospital, San Diego, and approved by the University of California, San Diego (UCSD) Human Research Protections Program. The requirement for informed consent was waived. All patients with DDPBF who underwent PDA stenting at our institution between January 2, 2013, and March 25, 2025, were retrospectively reviewed. A significant shift in institutional management occurred after 2017, transitioning to a universal PDA stenting strategy for all infants with DDPBF requiring palliation with a higher propensity toward preprocedural CT. In 2018, the institution also implemented 3D reconstruction capabilities. Patients were stratified into two categories: 3D reconstruction before intervention and no 3D reconstruction prior to intervention (3D reconstruction was performed post hoc where cross-sectional images were available. Nineteen patients were in the \u0026ldquo;non-3D group,\u0026rdquo; and twenty-seven patients were in the \u0026ldquo;3D group\u0026rdquo;; analysis started after the universal PDA stenting strategy was implemented. All cases were discussed and approved during multidisciplinary team conferences before intervention. Demographics, clinical characteristics, procedural details, and follow-up data were obtained from electronic medical records and securely stored in REDCap.\u003c/p\u003e \u003cp\u003eSegmentation and reconstruction of 3D models of patient anatomy were conducted using Mimics Innovation Suite (Version 25, Materialize, Leuven, Belgium). Patient images were imported and manually segmented based on intensity values (i.e., intensity value thresholding) to produce masks of the cardiac anatomy and airway. The following blood volumes were segmented from the main cardiac structure: aortic arch with outlet vessels, patent ductus arteriosus, and the pulmonary artery; major aortopulmonary collateral arteries (MAPCAs) were also reconstructed if present. Segmented masks were converted to 3D meshes and exported into Geomagic Wrap (3D Systems, Rock Hill, SC) for further processing and refinement. Noise removal and component refinement/labeling of each distinct cardiac segment were performed. Data was re-imported into Mimics to check for accuracy. Outputs from the reconstruction process in Mimics are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e(A). A centerline was constructed with a spline in Mimics along the aorta, PDA, and pulmonary arteries, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e(B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe distance along the centerline was used to determine the full length of the PDA and tortuosity along the PDA was calculated in Eq.\u0026nbsp;1. The tortuosity was also categorized based on the scheme outlined by Qureshi et al., as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The path between the outlet vessel and the proximal end of the PDA was qualitatively characterized through a spline tool, shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(Eq.\u0026nbsp;1)\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\text{T}\\text{o}\\text{r}\\text{t}\\text{u}\\text{o}\\text{s}\\text{i}\\text{t}\\text{y}\\:\\text{I}\\text{n}\\text{d}\\text{e}\\text{x}\\:=\\:\\frac{\\text{L}{-\\text{L}}_{\\text{s}}}{\\text{L}}\\:\\:$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:{\\text{L}}_{\\text{c}}:\\text{f}\\text{u}\\text{l}\\text{l}\\:\\text{l}\\text{e}\\text{n}\\text{g}\\text{t}\\text{h}\\:\\text{o}\\text{f}\\:\\text{P}\\text{D}\\text{A}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equc\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equc\" name=\"EquationSource\"\u003e\n$$\\:{\\text{L}}_{\\text{s}}:\\:\\text{l}\\text{e}\\text{n}\\text{g}\\text{t}\\text{h}\\:\\text{P}\\text{D}\\text{A}\\:\\text{m}\\text{e}\\text{a}\\text{s}\\text{u}\\text{e}\\text{d}\\:\\text{a}\\text{s}\\:\\text{a}\\:\\text{s}\\text{t}\\text{r}\\text{a}\\text{i}\\text{g}\\text{h}\\text{t}\\:\\text{l}\\text{i}\\text{n}\\text{e}\\:\\text{f}\\text{r}\\text{o}\\text{m}\\:\\text{o}\\text{r}\\text{i}\\text{g}\\text{i}\\text{n}\\:\\text{t}\\text{o}\\:\\text{i}\\text{n}\\text{s}\\text{e}\\text{r}\\text{t}\\text{i}\\text{o}\\text{n}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudy outcomes included quantitative and qualitative characterization of the ductus arteriosus as well as procedural metrics such as fluoroscopy time, contrast volume, and radiation dose. Reintervention rates were also evaluated. Reintervention was defined as any catheter-based procedure on the PDA stent, such as redilation or additional stent placement. Surgical procedures to enhance pulmonary blood flow, including shunt placement or early second-stage operations, were also classified as reinterventions. Baseline descriptive statistics were calculated for the study population. Continuous variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median [interquartile range]. Categorical variables were presented as frequencies and percentages. Between-group comparisons (3D modeling reconstruction preprocedural vs. no 3D modeling reconstruction) were performed using a t-test for continuous variables and Fisher\u0026rsquo;s exact test for categorical variables. Odds ratios (OR) with 95% confidence intervals were calculated for categorical comparisons. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient characteristic\u003c/h2\u003e\n \u003cp\u003eA total of 46 patients with DDPBF were included in the study, of whom 27 underwent preprocedural 3D reconstruction (\u0026ldquo;3D groups\u0026rdquo;) modeling, and 19 did not (\u0026ldquo;non-3D group\u0026rdquo;). Baseline demographic and clinical characteristics were comparable between groups. Median birth weight was similar between the 3D group (3.26 kg [IQR: 2.75\u0026ndash;3.64]) and the non-3D group (3.00 kg [IQR: 2.76\u0026ndash;3.30]). Age and weight at the time of the first intervention were also comparable. The incidence of prematurity and genetic syndromes did not differ significantly between cohorts.\u003c/p\u003e\n \u003cp\u003eBaseline anatomical diagnoses and procedural characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Single-ventricle physiology with pulmonary atresia predominated in the 3D modeling group, whereas PA with intact ventricular septum (PA/IVS) was the most frequent diagnosis in the non-3D cohort. Vascular access strategies differed between groups, with carotid and axillary access more commonly utilized in the 3D group, while femoral access predominated in the non-3D cohort. PDA morphology, classified by tortuosity index, was comparable between groups, with Type III ducts representing the most prevalent morphology in both cohorts.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Patients Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo 3D (n=19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3D (n=27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eSex (F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e10 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e12 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eBirth Weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e3 (2.76-3.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e3.26 (2.75-3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eAge at 1\u003csup\u003est\u003c/sup\u003e intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e8 (4.5-11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e9 (7-23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eWeight at 1\u003csup\u003est\u003c/sup\u003e intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e3.33 (3.12-3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e3.35 (3.07-3.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eAnatomic Diagnosis*\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePA/IVS\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTOF or DORV with PA or PS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTGA with PA\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSingle ventricle with PA (DILV, unbalanced AVC, TA)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eHeterotaxy with PA (TAPVR,\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eGestational age, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e39 (37/0.5-39/2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e38/6 (36/6.5-39/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003ePrematurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e4 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e6 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eGenetic Syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e5 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003eAccess\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFemoral\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eUAC\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAxillary\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCarotid\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (37%)\u003c/p\u003e\n \u003cp\u003e5 (26%)\u003c/p\u003e\n \u003cp\u003e6 (32%)\u003c/p\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (11%)\u003c/p\u003e\n \u003cp\u003e5 (19%)\u003c/p\u003e\n \u003cp\u003e9 (33%)\u003c/p\u003e\n \u003cp\u003e10 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45.4348%;\"\u003e\n \u003cp\u003ePDA Type\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eII\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIII\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.5217%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (26%)\u003c/p\u003e\n \u003cp\u003e6 (32%)\u003c/p\u003e\n \u003cp\u003e8 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.0435%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (19%)\u003c/p\u003e\n \u003cp\u003e10 (37%)\u003c/p\u003e\n \u003cp\u003e12 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e* PA/IVS: Pulmonary atresia with Intact Ventricular septum, TOF: Tetralogy of Fallot, DORV: Double outlet Right Ventricular, TGA: Transposition of Great Arteries, PA: Pulmonary Atresia, DILV: Double Inlet left Ventricular, Tetralogy of Fallot, TA: Tricuspid Atresia, TAPVR: Total Anomalous Pulmonary Venous Return, Other: Hypoplastic Left heart\u003c/p\u003e\n \u003cp\u003eSyndrome, Ebstein Anomaly, Situs Solitus.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eAmong all patients, those who underwent 3D reconstruction prior to intervention demonstrated improved procedural characteristics, particularly in terms of radiation exposure. Mean Air Kerma was significantly lower in the 3D group compared to those without prior 3D modeling (50.4 mGy vs 108 mGy, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0149), with a moderate effect size (0.36). Similarly, mean dose area product (DAP) was reduced in the 3D group (186 cGy\u0026middot;cm\u0026sup2; vs 344 cGy\u0026middot;cm\u0026sup2;, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0295). While mean case length and fluoroscopy time were shorter with 3D modeling, the differences did not reach statistical significance. The need for catheter-based re-intervention prior to definitive surgical repair was also lower in the 3D group (48.1% vs 78.9%), trending toward significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0644) with an odds ratio of 4.04 (95% CI: 1.06\u0026ndash;15.37). (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u0026nbsp;\u003c/p\u003e\n\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOutcomes by Time of 3D modeling\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eCase Length (min)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDid not Have 3D Prior\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eHad 3D Prior\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eEffect Size/OR\u003c/p\u003e\n \u003cp\u003e(95% C.I.)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e122 (68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e91.4 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.26 (-0.01, 0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1-Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e131 (76.0-144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e80.0 (60.5\u0026ndash;128)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFlouro Time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e26.4 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e19.8 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.2505\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.17 (-0.11, 0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1-Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e23.6 (14.0\u0026ndash;31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e14.8 (11.8\u0026ndash;24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAir Kerma (mGy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e108 (91.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e50.4 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.36 (0.09, 0.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1-Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e93.3 (44.3\u0026ndash;137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e36.2 (22.8\u0026ndash;66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDAP (cGy.cm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e344 (284)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e186 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.32 (0.05, 0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1-Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e297 (147\u0026ndash;469)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e123 (70.3\u0026ndash;222)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRe-intervention prior\u003c/p\u003e\n \u003cp\u003eto surgical repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e4 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e14 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e4.04 (1.06, 15.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e15 (78.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e13 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eIn the subgroup of patients with tortuosity index type II and III, these trends persisted. Air Kerma remained significantly lower in the 3D modeling group (54.4 mGy vs 115 mGy, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0449), and DAP showed a borderline significant reduction (200 cGy\u0026middot;cm\u0026sup2; vs 368 cGy\u0026middot;cm\u0026sup2;, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0714). Although differences in procedure duration and fluoroscopy time were not statistically significant in this subgroup. Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOutcomes by Time of 3D modeling in Subgroup of Tortuosity Type 2 and 3\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eCase Length (min)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDid not Have 3D Prior\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eHad 3D Prior\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eEffect Size/OR\u003c/p\u003e\n \u003cp\u003e(95% C.I.)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e124 (74.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e94.2 (43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.3066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.17 (-0.11, 0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e115 (71.0, 144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e85.0 (65.3, 128)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFlouro Time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e27.7 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e21.0 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.4703\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.12 (-0.18, 0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e23.3 (11.8, 31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e16.7 (12.6, 25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAir Kerma (mGy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e115 (98.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e54.4 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.36 (0.04, 0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e95.5 (41.4, 130)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e37.4 (24.0, 76.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDAP (cGy.cm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e368 (307)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e200 (175)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.0714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.30 (0.01, 0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e299 (157, 480)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e137 (68.0, 257)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRe-intervention Prior\u003c/p\u003e\n \u003cp\u003eto Surgical Repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e11 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e3.67 (0.79, 16.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11 (78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e11 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the impact of pre-procedural 3D modeling on PDA stenting, focusing on radiation exposure, efficiency, and the need for re-intervention. PDA stenting is an evolving procedure, with ongoing efforts to optimize outcomes by reducing complication rates, minimizing reintervention frequency, and enhancing overall procedural effectiveness (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our findings suggest that the use of 3D modeling prior to intervention is associated with significantly reduced radiation exposure, as evidenced by lower Air Kerma and DAP values. These findings were consistent across the full cohort and within the subgroup of patients with moderate to severe vascular tortuosity (types 2 and 3), indicating that the benefits of 3D modeling may be particularly valuable in anatomically complex cases.\u003c/p\u003e \u003cp\u003eWhen a pre-procedural CT scan has been performed, the subsequent angiogram in the catheterization lab can often be conducted using fluoroscopy alone, without the need for cine angiography. In this context, the goal is not to obtain detailed anatomical imaging but rather a procedural roadmap. Moreover, 3D CT data can be used to determine optimal angiographic angles prior to the procedure. By referencing the 3D reconstruction, the operator can directly position the imaging system in the best angulation\u0026mdash;whether RAO cranial, LAO cranial, or another view\u0026mdash;without requiring multiple acquisitions to determine the ideal projection. This approach helps reduce the number of angiographic runs, thereby lowering both radiation exposure and contrast use.\u003c/p\u003e \u003cp\u003eIn addition, while ionizing radiation from both CT and catheter-based procedures carries an associated long-term cancer risk(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), recent advancements in imaging techniques and scanning protocols have decreased radiation exposure from CT scans, with average effective doses of 1 millisievert (mSv) or less (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). While there are no established reference doses for PDA stenting, available data indicate that for infants under one year old, the radiation from chest CT angiography is considerably lower than that from diagnostic catheterization; median effective doses are approximately 0.76 mSv for CT and 13.4 mSv for catheter-based studies (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These findings support the selective use of low-dose pre-procedural CT imaging as a valuable adjunct in procedural planning, offering improvements in efficiency and safety without significantly increasing the overall radiation burden. Our study builds on this evidence by demonstrating that patients who underwent pre-procedural 3D modeling had significantly lower intra-procedural radiation exposure, highlighting the practical impact of this approach in a real-world cohort.\u003c/p\u003e \u003cp\u003ePDA stenting has emerged as an alternative to mBTTS, though it does carry a higher risk of reintervention(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This is partly since these patients often undergo scheduled interval catheterizations, during which both planned and incidental reinterventions may occur. The increased reintervention rate in the PDA stent group is largely attributable to the initial procedure. However, such reinterventions can be viewed as a potential advantage, as PDA stents act as \u0026ldquo;adjustable shunts\u0026rdquo; that can be expanded to accommodate somatic growth.\u003c/p\u003e \u003cp\u003eA common reason for early reintervention following PDA stenting is incomplete coverage of the ductus by the initial implant(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Full ductal coverage can often prevent this complication, even if it results in the stent protruding into the pulmonary artery or the aorta during the initial procedure.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Pre-procedural 3D modeling can aid in preventing such complications by providing precise anatomical visualization, allowing for more accurate stent sizing and positioning.\u003c/p\u003e \u003cp\u003eMost reinterventions involve stent re-dilation and placement of an additional stent to address restenosis. However, catheter-based approaches are not always sufficient, necessitating surgical revision or shunt placement(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In our cohort, patients who underwent pre-procedural 3D modeling demonstrated a trend toward lower unplanned reintervention rates, nearing statistical significance (p\u0026thinsp;=\u0026thinsp;0.0644). Although this difference did not reach conventional significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), the observed trend supports the notion that 3D modeling enhances initial procedural planning and execution, potentially reducing the need for further interventions before definitive surgical repair (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, pre-procedural 3D reconstruction was associated with a significant reduction in radiation exposure and a trend toward improved procedural efficiency and reduced need for reintervention. These findings suggest that enhanced anatomical understanding prior to intervention may facilitate more precise procedural planning, particularly in patients with complex ductal morphology. Given the increasing use of PDA stenting as a primary palliative strategy in ductal-dependent pulmonary blood flow, integration of 3D reconstruction into routine pre-procedural workflows may represent an important step toward improving both procedural safety and outcomes. Future prospective studies with larger cohorts are warranted to further validate these findings and define the role of 3D-guided planning in optimizing interventional strategies in this high-risk population.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations. First, the sample size was relatively small, which may limit the statistical power and generalizability of our findings. Second, Prostaglandin-E1 (PGE-1) is used to keep the ductus arteriosus patent and can be life-saving in neonates with ductal-dependent PBF.\u003csup\u003e31\u003c/sup\u003e Patients with ductal-dependent PBF are often reliant on PGE-1 in ensuring patency and preventing constriction of the PDA prior to PDA stenting.\u003csup\u003e12\u003c/sup\u003e In this patient cohort, all 3D reconstructions of the PDA are of patients who were, at the time, infused with PGE-1. However, several hours prior to stenting, the patient is taken off PGE-1 to prepare for catheterization. As such, there may be a discrepancy in the diameter, tortuosity, straight length, and full length of the reconstructed PDA compared to true PDA measurements at the time of stenting in the catheter lab.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of pre-procedural 3D modeling in PDA stenting appears to offer meaningful clinical benefits, including reduced radiation exposure and a lower likelihood of requiring catheter-based reintervention, particularly in patients with complex ductal anatomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare that there are no conflicts of interest related to this study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics statement and patient consent\u003c/h2\u003e \u003cp\u003e The study was conducted following the research protocols and was approved by the relevant institutional review boards at the University of San Diego.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding sources\u003c/h2\u003e \u003cp\u003eThis research did not receive funding support from public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.P. was responsible for data collection. M.H. contributed to data writing analysing the data. J.R. and M.J. performed the visualization. K.S. oversaw data accuracy and provided supervision. H.E. conceived the research idea and supervised the project.\u003c/p\u003e\u003ch2\u003eAcknowledgment:\u003c/h2\u003e \u003cp\u003eWe would like to express our gratitude to Helen and the Will Webster Foundation for their support of the 3D Innovations Lab at Rady Children's Hospital, San Diego, CA, USA.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlalock A, Taussig HB, Landmark article, May (1945) 19, : The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. By Alfred Blalock and Helen B. Taussig. Jama. 1984;251(16):2123-38\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRatnayaka K, Nageotte SJ, Moore JW, Guyon PW, Bhandari K, Weber RL et al (2021) Patent Ductus Arteriosus Stenting for All Ductal-Dependent Cyanotic Infants: Waning Use of Blalock-Taussig Shunts. Circ Cardiovasc Interv 14(3):e009520\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdelMassih AF, Menshawey R, Menshawey E, El-Maghraby AE, Sabry AO, Kamel A et al (2022) Blalock-Taussig shunt versus ductal stent in the palliation of duct dependent pulmonary circulation; a systematic review and metanalysis. Curr Probl Cardiol 47(9):100885\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlatz AC, Petit CJ, Goldstein BH, Kelleman MS, McCracken CE, McDonnell A et al (2018) 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 137(6):589\u0026ndash;601\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsagheir A, Koziarz A, Makhdoum A, Contreras J, Alraddadi H, Abdalla T et al (2021) 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 161(2):379\u0026ndash;390 e8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi D, Zhou X, Li M (2021) Arterial duct stent versus surgical shunt for patients with duct-dependent pulmonary circulation: a meta-analysis. BMC Cardiovasc Disord 21(1):9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBentham JR, Zava NK, Harrison WJ, Shauq A, Kalantre A, Derrick G et al (2018) 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 137(6):581\u0026ndash;588\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJustino H, Petit CJ (2016) Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization. Circ Cardiovasc Interv 9(4):e003003\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHesari M, Ng\u0026rsquo;eno M, Gordon BM, AlShawabkeh L, Ryan JR, Fulk C et al (2025) The Wire Twisting/Locking Technique to Facilitate Precise PDA Stent Delivery in Neonates with Ductal-Dependent Pulmonary Blood Flow. Pediatr Cardiol. :1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg\u0026rsquo;eno M, Gordon BM, Rao R, Ryan JR, Haley J, Ganta S et al (2025) The fate of the jailed branch: challenging the dogma of PDA stenting in cases with a pulmonary artery branch originating from the PDA. Pediatr Cardiol. :1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite SC, Sedler J, Jones TW, Seckeler M (2018) Utility of three-dimensional models in resident education on simple and complex intracardiac congenital heart defects. Congenit Heart Dis 13(6):1045\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlivieri L, Krieger A, Chen MY, Kim P, Kanter JP (2014) 3D heart model guides complex stent angioplasty of pulmonary venous baffle obstruction in a Mustard repair of D-TGA. Int J Cardiol 172(2):e297\u0026ndash;e298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValverde I, Gomez G, Gonzalez A, Suarez-Mejias C, Adsuar A, Coserria JF et al (2015) Three-dimensional patient-specific cardiac model for surgical planning in Nikaidoh procedure. Cardiol Young 25(4):698\u0026ndash;704\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiesenkampff E, Rietdorf U, Wolf I, Schnackenburg B, Ewert P, Huebler M et al (2009) The practical clinical value of three-dimensional models of complex congenitally malformed hearts. J Thorac Cardiovasc Surg 138(3):571\u0026ndash;580\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobs S, Grunert R, Mohr FW, Falk V (2008) 3D-Imaging of cardiac structures using 3D heart models for planning in heart surgery: a preliminary study. Interact Cardiovasc Thorac Surg 7(1):6\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwori J, Friedman SD, Chan T, Howard C, Seslar S, Soriano BD et al (2021) 3D models improve understanding of congenital heart disease. 3D Print Med 7(1):26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSodian R, Weber S, Markert M, Rassoulian D, Kaczmarek I, Lueth TC et al (2007) Stereolithographic models for surgical planning in congenital heart surgery. Ann Thorac Surg 83(5):1854\u0026ndash;1857\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J, Ratnayaka K, Moore J, El-Said H (2019) Stenting the vertical neonatal ductus arteriosus via the percutaneous axillary approach. Congenit Heart Dis 14(5):791\u0026ndash;796\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoo HW, Park SJ, Yoo SJ (2020) Advanced Medical Use of Three-Dimensional Imaging in Congenital Heart Disease: Augmented Reality, Mixed Reality, Virtual Reality, and Three-Dimensional Printing. Korean J Radiol 21(2):133\u0026ndash;145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreil GF, Wolf I, Kuettner A, Fenchel M, Miller S, Martirosian P et al (2007) Stereolithographic reproduction of complex cardiac morphology based on high spatial resolution imaging. Clin Res Cardiol 96(3):176\u0026ndash;185\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlejn\u0026iacute;k P, Nosal M, Havran T, Furdova A, Cizmar M, Slabej M et al (2017) Utilisation of three-dimensional printed heart models for operative planning of complex congenital heart defects. Kardiol Pol 75(5):495\u0026ndash;501\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi AM, Goldstein BH, Glatz AC, Agrawal H, Aggarwal V, Ligon RA et al (2019) 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 93(5):933\u0026ndash;943\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValdeomillos E, Jalal Z, Boudjemline Y, Thambo J-B (2020) Transcatheter ductus arteriosus stenting in paediatric cardiology: indications, results and perspectives. Arch Cardiovasc Dis 113(2):129\u0026ndash;141\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIssa B, Hesari M, Gordon BM, Ryan JR, Hedberg A, Fulk C et al (2025) Innovative Use of Coronary GuideLiner to Facilitate Patent Ductus Arteriosus Stent Reintervention. J Soc Cardiovasc Angiography Interventions. :103576\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrody AS, Frush DP, Huda W, Brent RL (2007) Radiation risk to children from computed tomography. Pediatrics 120(3):677\u0026ndash;682\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCevallos PC, Armstrong AK, Glatz AC, Goldstein BH, Gudausky TM, Leahy RA et al (2017) Radiation dose benchmarks in pediatric cardiac catheterization: A prospective multi-center C3PO-QI study. Catheter Cardiovasc Interv 90(2):269\u0026ndash;280\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeinel FG, Henzler T, Schoepf UJ, Park PW, Huda W, Spearman JV et al (2015) ECG-synchronized CT angiography in 324 consecutive pediatric patients: spectrum of indications and trends in radiation dose. Pediatr Cardiol 36(3):569\u0026ndash;578\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRigsby CK, McKenney SE, Hill KD, Chelliah A, Einstein AJ, Han BK et al (2018) Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently 'Have-A-Heart' campaign. Pediatr Radiol 48(1):5\u0026ndash;20\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatson TG, Mah E, Joseph Schoepf U, King L, Huda W, Hlavacek AM (2013) Effective radiation dose in computed tomographic angiography of the chest and diagnostic cardiac catheterization in pediatric patients. Pediatr Cardiol 34(3):518\u0026ndash;524\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRatnayaka K, Nageotte SJ, Moore JW, Guyon PW, Bhandari K, Weber RL et al (2021) Patent ductus arteriosus stenting for all ductal-dependent cyanotic infants: waning use of Blalock-Taussig shunts. Circulation: Cardiovasc Interventions 14(3):e009520\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLekchuensakul S, Somanandana R, Namchaisiri J, Benjacholamas V, Lertsapcharoen P (2022) Outcomes of duct stenting and modified Blalock\u0026ndash;Taussig shunt in cyanotic congenital heart disease with duct-dependent pulmonary circulation. Heart Vessels. :1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi AM, Goldstein BH, Glatz AC, Agrawal H, Aggarwal V, Ligon RA et al (2019) 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 93(5):933\u0026ndash;943\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBentham JR, Zava NK, Harrison WJ, Shauq A, Kalantre A, Derrick G et al (2018) 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 137(6):581\u0026ndash;588\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallula K, Vaughn G, El-Said H, Lamberti JJ, Moore JW (2015) Comparison of ductal stenting versus surgical shunts for palliation of patients with pulmonary atresia and intact ventricular septum. Catheter Cardiovasc Interv 85(7):1196\u0026ndash;1202\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcMullan DM, Permut LC, Jones TK, Johnston TA, Rubio AE (2014) Modified Blalock-Taussig shunt versus ductal stenting for palliation of cardiac lesions with inadequate pulmonary blood flow. J Thorac Cardiovasc Surg 147(1):397\u0026ndash;401\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"PDA, 3D reconstruction, Patent ductus arteriosus, PDA stenting, radiation exposure","lastPublishedDoi":"10.21203/rs.3.rs-9228884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9228884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eManaging patients with patent ductus arteriosus (PDA) and complex anatomical features, such as tortuosity and branching anomalies, remains a challenge in interventional cardiology. Recent advances in three-dimensional (3D) reconstruction and quantitative analysis of ductal anatomy have shown promise in improving procedural outcomes. This study evaluates the utility of 3D reconstruction in pre-procedural planning for PDA stenting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective, single-center study included patients who underwent PDA stenting or modified Blalock-Taussig-Thomas from January 2010 to March 2025. Pre-procedural 3D reconstruction was performed for a subset of patients, allowing for detailed analysis of ductal tortuosity, vessel diameter, and other anatomic variables. Procedural outcomes, including radiation exposure, procedure time, and the need for reintervention, were compared between the 3D and non-3D-guided groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 46 patients were included in the analysis, with 26 having preprocedural 3D-guided planning. The 3D group demonstrated significantly lower mean Air Kerma (50.4 vs 108 mGy, p\u0026thinsp;=\u0026thinsp;0.0149) and dose area product (186 vs 344 cGy\u0026middot;cm\u0026sup2;, p\u0026thinsp;=\u0026thinsp;0.0295). Case length and fluoroscopy time were shorter but not statistically significant. There was a trend toward fewer reinterventions in the 3D group (10% vs 18%, p\u0026thinsp;=\u0026thinsp;0.06). Stratification by tortuosity type revealed that 3D planning was particularly beneficial in cases with high tortuosity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePreprocedural 3D reconstruction is a valuable tool in planning PDA interventions with a high success rate and significantly lower radiation exposure. These findings support the incorporation of 3D modeling into routine clinical practice for complex PDA cases, potentially improving procedural efficiency and patient outcomes.\u003c/p\u003e","manuscriptTitle":"PDA Stenting With Versus Without Pre-Procedural 3D Reconstruction: Impact on Radiation Exposure and Procedural Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-01 07:23:08","doi":"10.21203/rs.3.rs-9228884/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-05T09:46:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T07:59:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264299944527851268341807380710742424837","date":"2026-04-28T00:01:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T08:19:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318550500708159854726756896629561735753","date":"2026-04-04T18:40:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203025815817690439140624758940439804433","date":"2026-04-01T15:05:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-30T08:24:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-26T14:34:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-26T07:27:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2026-03-26T03:40:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5a2cae9a-fa54-48e9-9579-27e100aed31d","owner":[],"postedDate":"April 1st, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-05T09:46:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T07:59:15+00:00","index":11,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T10:07:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-01 07:23:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9228884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9228884","identity":"rs-9228884","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}