ORIGINAL ARTICLE – CONGENITAL
Interactive CardioVascular and Thoracic Surgery 20 (2015) 499–503 doi:10.1093/icvts/ivu435 Advance Access publication 6 January 2015
Cite this article as: Lynch W, Boekholdt SM, Hazekamp MG, de Winter RJ, Koolbergen DR. Hybrid branch pulmonary artery stent placement in adults with congenital heart disease. Interact CardioVasc Thorac Surg 2015;20:499–503.
Hybrid branch pulmonary artery stent placement in adults with congenital heart disease Winston Lyncha, S. Mathijs Boekholdtb, Mark G. Hazekampa,c, Robbert J. de Winterb and David R. Koolbergena,c,* b c
Department of Cardiothoracic Surgery, Academic Medical Centre, Amsterdam, Netherlands Department of Cardiology Academic Medical Centre, Amsterdam, Netherlands Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
* Corresponding author. Department of Cardiothoracic Surgery, Academic Medical Centre, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. Tel: +31-205-66911; fax: +31-206-962289; e-mail: [email protected]; [email protected] (D.R. Koolbergen). Received 17 September 2014; received in revised form 20 November 2014; accepted 25 November 2014
Abstract OBJECTIVES: Valuable treatment modalities for branch pulmonary artery (BPA) stenoses are surgical patch angioplasty, percutaneous BPA stenting and hybrid stent placement. The purpose of this study was to report our institutional experience with hybrid stent placement to relieve BPA stenoses. METHODS: Between August 2007 and May 2014, 7 adults (5 females) with congenital heart disease (CHD) had elective intraoperative BPA stent placement. All 7 patients had undergone previous surgery [6 tetralogy of Fallot repairs and 1 arterial switch operation for transposition of the great arteries (TGAs)]. A total of 7 stents (4 right pulmonary artery, 3 left pulmonary artery) were implanted under direct vision, concomitant with a pulmonary homograft implantation (tetralogy of Fallot patients), or because percutaneous stenting was not feasible (TGA patient). Retrospective analysis of clinical data, procedural details and outcomes was performed. RESULTS: Overall, the mean age was 35 ± 7.2 years. Stent implantation was successful in all procedures. The mean postinflation stent diameter was 13.3 ± 2.0 mm. No stent migration, fracture, stent thrombosis, reintervention or deaths occurred. In 1 case the procedure was complicated by a right pulmonary artery tear just distal to the stent which was repaired by surgical patch angioplasty. At a mean follow-up of 55.6 ± 26 months no patient required catheter reintervention or surgery. Echocardiography (mean follow-up 47.1 ± 22 months), MRI (mean follow-up 43.8 ± 37 months) and CT data (mean follow-up 14.8 ± 10 months) demonstrate a BPA diameter increment from a mean 5.57 ± 2.29 to 10.71 ± 2.56 mm. CONCLUSIONS: Hybrid intraoperative BPA stent placement is safe and effective and can be used as an alternative for surgical patch angioplasty or if percutaneous BPA stenting is not feasible. Short- to mid-term results are good. Keywords: Congenital heart disease • Stent • Hybrid • Branch pulmonary artery
INTRODUCTION Branch pulmonary artery (BPA) stenosis is commonly associated with many congenital heart diseases (CHDs). Unilateral stenosis of one of the pulmonary artery (PA) branches causes a significant decrement of the PA branch flow and perfusion of the affected lung [1]. It can also potentially worsen pulmonary insufficiency in patients with repaired tetralogy of Fallot [2]. Surgical patch angioplasty and percutaneous BPA stenting are established treatment options for BPA stenosis [3, 4]. Percutaneous stenting is equally as effective as surgery in the treatment of BPA stenosis [5]. Surgical patch angioplasty can be a technically challenging procedure whereby stenosis commonly recurs due to compression on the patch from surrounding structures. However, percutaneous stenting is not always feasible due to right ventricular outflow
obstruction or difficult vascular access. After favourable results from intraoperative stenting of pulmonary arteries in small children [6], we recently described our first experiences with hybrid BPA stent placement in adult tetralogy of Fallot patients [7]. In our current study, the short and mid-term results of hybrid BPA stent placement are presented in an extended series of adult patients with CHD, including echocardiographic and radiographic followup with cardiac computerized tomography (CT) or cardiac magnetic resonance angiography (MRA).
MATERIALS AND METHODS A retrospective review of our surgical database of consecutive adult patients with CHD who underwent hybrid BPA stent
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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placement at our institution from August 2007 to May 2014 was performed. Retrospective analysis of clinical data, procedural details and outcomes was done.
The hybrid procedures The hybrid procedures combined both surgical and interventional techniques. All procedures were performed in a conventional cardiac operating theatre (OT) and on cardiopulmonary bypass (CPB). On a beating heart the pulmonary trunk was incised longitudinally and the PA branches were visualized directly (see Video 1). In the TGA patient a stent previously placed in the RPA was trimmed to free the way for the LPA stent placement. For inspection of the RPA stenosis following Waterston shunt, always directly behind and hidden by the ascending aorta, a prewarmed dental mirror was used. Positioning the mirror in the pulmonary confluence provided a clear view of the stenosis and then of the position and development of the stent. The length of the stent was selected on the basis of the vessel diameter as visualized by preoperative imaging by MRA or computerized tomography angiography, the location of the stenosis and intraoperative anatomical findings (see Fig. 1A and B). Bare Cheatham Platinum stents (NuMed, Inc., Hopkinton, New York, NY, USA) were implanted at all procedures. The Bare Cheatham Platinum stent was handcrimped on a SHYTAK II or Z-Med II balloon and placed over a guide wire across the lesion by the interventional cardiologist (see Video 1). The balloon was inflated in accordance with the manufacturer’s guidelines. When necessary, multiple balloon inflations were carried out to ensure full expansion of the stent. The stent was positioned under direct vision of the proximal part of the stent and the distal aspect was palpated digitally to ensure that the stent would not compromise the ostium of the upper lobe branch of the PA. Neither intraoperative fluoroscopy nor angiography were used. The proximal end of the stent was flared and it was then secured to the BPA wall by suture to prevent stent migration (see Video 1). At the end of surgery, intraoperative transoesophageal echocardiography was also utilized to confirm that the stent was appropriately positioned. Anticoagulant therapies used in the first 5 cases were aspirin and clopidrogel for 6 months; in Cases 6 and 7 clopidrogel therapy was reduced to 1 month. All patients had the follow-up echocardiograms and MRIs or CT scans. Outcome measures were procedural stent complications (stent malposition, stent fracture, stent migration/embolization or stent removal), BPA tear/rupture, diameter increment of the stenotic BPA segment and need for reintervention.
RESULTS During the study period, 7 adults (5 females) with CHD had elective intraoperative BPA stent placement. The mean age was 35 ± 7.2 years (see Table 1). All 7 patients had undergone cardiac surgery at an early age (6 total surgical repairs of tetralogy of Fallot and 1 arterial switch operation for TGAs). A total of 7 stents were implanted: 4 in the right pulmonary artery (RPA) and 3 in the left pulmonary artery (LPA). Concomitant surgical procedures performed were pulmonary homograft implantation (6 Fallot patients), tricuspid valve repair (2 Fallot patients) and surgical patch angioplasty (1 Fallot patient) (see Table 1). The RPA stent placements were done in patients previously treated with a Waterston shunt and total repair of tetralogy of Fallot. These patients had RPA stenoses at the previous anastomosis site of the Waterston shunt. Two Fallot patients had long segment stenosis of the LPA. The TGA patient had a left BPA stenosis not feasible for percutaneous stenting because of a previous stent in the RPA, partially covering the origin of the LPA. No concomitant procedure was performed in this patient. Procedures were completed successfully in all patients. The mean postinflation stent diameter was 13.3 ± 2.0 mm and the mean CPB time 117.4 ± 26.5 min. Aortic clamping was necessary in 2 cases. In 1 case it was necessary for repair of an RPA tear after stenting and in the other case because of the suboptimal exposition of the RPA ostium due to excessive collateral flow. Complications of initial stent placement (see Table 2) included the above-mentioned RPA tear, just distal to the stent, which was repaired by additional surgical patch angioplasty. In this case, 2 balloon inflations from 4 to 8 atmospheres to expand the Bare Cheatham Platinum stent in the RPA did not exceed the manufacturer’s guidelines. The postoperative course was uneventful in 6 patients. One patient developed a pneumothorax which was successfully managed with tube thoracostomy. The mean intensive care unit stay was 1.3 ± 0.5 days and the mean hospital stay was 7.7 ± 1.3 days. No mortality was associated with initial stent implantation. At the mean follow-up of 55.6 ± 26 months no patient required catheter reintervention or surgery. There were no cases of stent migration, stent fracture, stent thrombosis or reintervention. Echocardiography (mean follow-up 47.1 ± 22 months), MRA (mean follow-up 43.8 ± 37 months) and CT (mean follow-up 14.8 ± 10 months) data of 7 patients, demonstrated a BPA diameter increment from a mean 5.57 ± 2.29 to 10.71 ± 2.56 mm (see Fig. 1C). In 1 patient, a follow-up pulmonary angiogram was performed (see Fig. 1D). In 1 patient who for social reasons could not be followed up the first 7 years after the hybrid procedure, echocardiography and MRA findings were normal.
DISCUSSION
Video 1: Hybrid pulmonary stent placement in a stenotic left BPA. BPA: branch pulmonary artery.
Primary and secondary BPA stenoses are common problems in CHD. For example, in tetralogy of Fallot severe stenosis can develop at the site of a previously closed Waterston shunt in the RPA branch directly behind the aorta [7, 8]. Branch PA stenosis requires aggressive treatment to improve right ventricular pressure and to provide balanced pulmonary blood flow. Valuable treatment modalities for BPA stenoses are percutaneous stenting, surgical patch angioplasty and hybrid intraoperative stent placement. Endovascular stent placement for the treatment of BPA stenosis was introduced in 1991 [9].
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Figure 1: ( A) Preoperative CT angiogram demonstrating width measurement of the narrowed right pulmonary artery; (B) preoperative CT angiogram demonstrating length measurement from the ostium of the right pulmonary artery to the upper lobe branch; (C) the follow-up CT angiogram with a stent in the right pulmonary artery; (D) the follow-up pulmonary angiogram with a stent in the right pulmonary artery.
Table 1: Patient characteristics (n = 7) No
Sex
Age (years)
Weight (kg)
Previous surgery
Concomitant procedure
1 2 3 4
F F F F
38 41 39 21
70 79 103 60
PHG PHG PHG and angioplasty LPA No concomitant procedure
5 6 7
M M F
39 30 39
78 73 60
Repair TOF and Waterston shunt Repair TOF and Waterston shunt Repair TOF and Waterston shunt ASO, patch angioplasty RPA and LPA, percutaneous stent RPA and LPA Repair TOF and Waterston shunt Repair TOF Repair TOF
PHG and TVR PHG PHG and TVR
TOF: tetralogy of Fallot; PHG: pulmonary homograft; RPA: right pulmonary artery; LPA: left pulmonary artery; ASO: arterial switch operation; TVR: tricuspid valve repair.
Percutaneous stenting is an established treatment modality for BPA stenosis [10, 11], but early complications of percutaneous stenting are common [12]. In patients with CHD who have previously had surgery, surgical patch angioplasty for BPA stenosis may be challenging due to difficulty in accessing distal PA stenoses and the RPA behind the aorta, or in accessing complex stenoses with fibrosis, calcification or hypoplasia of the BPA. Difficult surgical access, bleeding and excessive collateral blood flow lead to longer duration of surgery, longer CPB time and the need for circulatory arrest.
Hybrid intraoperative stent placement is an optional treatment for BPA stenosis in the following situations: (i) percutaneous stenting is difficult or impossible because of limited vascular access or complex anatomy; (ii) as surgery concomitant with other surgical procedures and if surgical patch angioplasty is not feasible [13, 14]; (iii) as rescue treatment following complications of percutaneous stenting [12, 15, 16]. At our centre, 58% of the total number of patients receiving pulmonary stents or surgical patch angioplasty had undergone hybrid intraoperative stent placement. Also, 6 previously operated
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Table 2: Details of the procedure and follow-up No
Stent position
Stent Ø (mm)
Complications
Follow-up investigations
Follow-up (months)
1 2 3 4 5 6
RPA RPA RPA LPA RPA LPA
14 12 15 12 15 10
No No Rupture RPA No No No
84 39 85 33 80 38
7
LPA
15
No
Echocardiography, MRA Echocardiography, MRA Echocardiography, MRA Echocardiography, MRA, CT Echocardiography, MRA, CT angiography Echocardiography, CT angiography, Pulmonary angiography Echocardiography, MRA, CT
30
RPA: right pulmonary artery; LPA: left pulmonary artery; Ø: diameter; CT: computerized tomography; MRA: magnetic resonance angiography.
tetralogy of Fallot patients needed treatment for BPA stenosis concomitant with pulmonary homograft implantation. The indications for performing hybrid intraoperative stent placement in these patients were (i) to lower the level of complexity of reoperations without performing additional surgical patch angioplasty, (ii) to shorten the surgical procedure and CPB time by lowering the level of difficulty of BPA dissection and access due to adhesions, scarring or bleeding, (iii) to be able to reach poorly accessible anatomical sites for surgical patch angioplasty such as an RPA behind the aorta or a long segment LPA stenosis with adhesions after previous surgery and (iv) to reduce the risk of restenosis following surgical patch angioplasty (due to compression from surrounding structures). The TGA patient needed hybrid intraoperative stent placement for BPA stenosis but no concomitant surgery. The indication was a left BPA stenosis unsuitable for percutaneous stent placement due to previous stent placement in the RPA, partially covering the origin of the LPA. Complications associated with hybrid intraoperative stent placement are (i) PA dissection or tear, (ii) stent migration, (iii) incomplete expansion of stent, (iv) stent thrombosis, (v) obstruction of smaller PA branches, (vi) in-stent restenosis, (vii) inhibition of PA growth and (viii) transient pulmonary oedema [17–21]. In our cohort, 1 of 7 (14%) patients needed surgical patch angioplasty intervention for an RPA tear. This could be explained by circumferential surgical dissection of the RPA prior to stent placement. The presence of scar tissue around the BPA may be of benefit in hybrid intraoperative stent placement by providing support during stent expansion and thereby preventing BPA tears [16, 22– 24]. Angtuaco et al. [22] reported 5 of 67 (7%) patients with BPA tears as the initial complication of hybrid stent placement. Ungerleider et al. [14] reported 2 of 27 (7%) patients with BPA tears and Mitropoulos et al. [24] experienced no perioperative morbidity during intraoperative stent placement. To prevent tear or rupture during intraoperative stent placement, extensive surgical dissection of the BPA and balloon over-inflation, i.e. exceeding manufacturer’s guidelines, should be avoided. Hybrid intraoperative stent placement has some important advantages: (i) control of vascular ruptures; (ii) prevention of stent migration; (iii) shortening of CPB time or clamp time; (iv) avoiding the need to transect the ascending aorta for patch angioplasty of the RPA; and (v) support for a repaired BPA, thus preventing collapse. In all our cases, direct vision, the use of a dental mirror and digital palpation were sufficient to achieve accurate stent positioning and placement, thus making fluoroscopy or angiography unnecessary and the procedure achievable in any conventional cardiac OT. Stent migration can be prevented by accurate stent
placement across the stenotic BPA, flaring the proximal end of the stent and suturing it to the BPA wall. In our study, during a mean follow-up of 55.6 ± 26 months there were no cases of stent thrombosis or in-stent restenosis. Echocardiography, MRA and CT follow-up data were satisfactory, showing a diameter increment of at least 40%, with a theoretical exponential increase in orifice area. Still, longer-term results have to be awaited. It is clear that close collaboration between cardiac surgeons and interventional cardiologists is essential in this hybrid management strategy. The constantly growing population of adults with a history of surgery for congenital heart defects means that more indications for hybrid BPA stent placement can be expected in a broad spectrum of diagnoses such as pulmonary atresia, truncus arteriosus and all cases where pulmonary arteries have previously been surgically or interventionally addressed. In conclusion, hybrid intraoperative BPA stent placement is a safe and effective technique that can be used as an alternative to surgical patch angioplasty, or in cases where percutaneous BPA stenting is not feasible in patients with CHD undergoing cardiac reoperations. It can be safely performed without fluoroscopy. Short- to mid-term results are excellent. Conflict of interest: none declared.
REFERENCES [1] Oyen WJG, van Oort AM, Tanke RB, van Mill GJ, Aengevaeren WRM, Corstens FHM. Pulmonary perfusion after endovascular stenting of pulmonary artery stenosis. J Nucl Med 1995;36:2006–8. [2] Chaturvedi RR, Kilner PJ, White PA, Bishop A, Szwarc R, Redington AN. Increased airway pressure and simulated branch pulmonary artery stenosis increase pulmonary regurgitation after repair of tetralogy of Fallot. Circulation 1997;95:643–9. [3] Bacha EA, Kreutzer J. Comprehensive management of branch pulmonary arterystenoses. J Interv Cardiol 2001;14:367–75. [4] McGoon DC, Kincaid OW. Stenosis of branches of the pulmonary artery: surgical repair. Med Clin North Am 1964;48:1083–8. [5] Trant CA Jr, O’Laughlin MP, Ungerleider RM, Garson A Jr. Cost-effectiveness analysis of stents, balloon angioplasty, and surgery for the treatment of branch pulmonary artery stenosis. Pediatr Cardiol 1997;18:339–44. [6] Bökenkamp R, Blom NA, De Wolf D, Francois K, Ottenkamp J, Hazekamp MG. Intraoperative stenting of pulmonary arteries. Eur J Cardiothorac Surg 2005;27:544–7. [7] Windhausen F, Boekholdt SM, Bouma BJ, Groenink M, Backx AP, de Winter RJ et al. Per-operative stent placement in the right pulmonary artery; a hybrid technique for the management of pulmonary artery
[8]
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branch stenosis at the time of pulmonary valve replacement in adult Fallot patients. Neth Heart J 2011;19:432–5. Wilson JM, Mack JW, Turley K, Ebert PA. Persistent stenosis and deformity of the right pulmonary artery after correction of the Waterston anastomosis. J Thorac Cardiovasc Surg 1981;82:169–75. O’Laughlin MP, Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation 1991;83:1923–39. Fogelman R, Nykanen D, Smallhorn J, McCrindle BW, Freedom RM, Benson LN. Endovascular stents in the pulmonary circulation: clinical impact on management and medium-term follow-up. Circulation 1995;92:881–5. Bergersen L, Lock JE. What is the current option of first choice for treatment of pulmonary arterial stenosis? Cardiol Young 2006;16:329–38. van Gameren M, Witsenburg M, Takkenberg JJ, Boshoff D, Mertens L, van Oort AM et al. Early complications of stenting in patients with congenital heart disease: a multicentre study. Eur Heart J 2006;27:2709–15. Mendelsohn AM, Bove EL, Lupinetti FM, Crowley DC, Lloyd TR, Fedderly RT et al. Intraoperative and percutaneous stenting of congenital pulmonary artery and vein stenosis. Circulation 1993;88(5 Pt 2):II210–217. Ungerleider RM, Johnston TA, O’Laughlin MP, Jaggers JJ, Gaskin PR. Intraoperative stents to rehabilitate severely stenotic pulmonary vessels. Ann Thorac Surg 2001;71:476–81. Hjortdal VE, Redington AN, de Leval MR, Tsang VT. Hybrid approaches to complex congenital cardiac surgery. Eur J Cardiothorac Surg 2002;22: 885–90. Bacha EA, Hijazi ZM, Cao QL, Starr JP, Waight D, Koenig P et al. New therapeutic avenues with hybrid paediatric cardiac surgery. Heart Surg Forum 2004;7:33–40.
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[17] Menon S, Cetta F, Dearani J, Burkhart HA, Cabalka AK, Hagler DJ. Hybrid intraoperative pulmonary artery stent placement for congenital heart disease. Am J Cardiol 2008;102:1737–41. [18] Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol 1990;65: 793–7. [19] Arnold LW, Keane JF, Kan JS, Fellows KE, Lock JE. Transient unilateral pulmonary edema after successful balloon dilation of peripheral pulmonary artery stenosis. Am J Cardiol 1988;62:327–30. [20] Baker CM, McGowan FX, Keane JF, Lock JE. Pulmonary artery trauma due to balloon dilation: recognition, avoidance and management. J Am Coll Cardiol 2000;36:1684–90. [21] Bush DM, Hoffman TM, Del Rosario J, Eiriksson H, Rome JJ. Frequency of restenosis after balloon pulmonary arterioplasty and its causes. Am J Cardiol 2000;86:1205–9. [22] Angtuaco MJ, Sachdeva R, Jaquiss RD, Morrow WR, Gossett JM, Fontenot E et al. Long-term outcomes of intraoperative pulmonary artery stent placement for congenital heart disease. Catheter Cardiovasc Interv 2011; 77:395–9. [23] Holzer RJ, Chisolm JL, Hill SL, Olshove V, Phillips A, Cheatham JP. Hybrid stent delivery in the pulmonary circulation. J Invasive Cardiol 2008;20: 593–8. [24] Mitropoulos FA, Laks H, Kapadia N, Gurvitz M, Levi D, Williams R et al. Intraoperative pulmonary artery stenting: an alternative technique for the management of pulmonary artery stenosis. Ann Thorac Surg 2007;84: 1338–42.
ORIGINAL ARTICLE
W. Lynch et al. / Interactive CardioVascular and Thoracic Surgery
Interactive CardioVascular and Thoracic Surgery 20 (2015) 499–503 doi:10.1093/icvts/ivu435 Advance Access publication 6 January 2015
Cite this article as: Lynch W, Boekholdt SM, Hazekamp MG, de Winter RJ, Koolbergen DR. Hybrid branch pulmonary artery stent placement in adults with congenital heart disease. Interact CardioVasc Thorac Surg 2015;20:499–503.
Hybrid branch pulmonary artery stent placement in adults with congenital heart disease Winston Lyncha, S. Mathijs Boekholdtb, Mark G. Hazekampa,c, Robbert J. de Winterb and David R. Koolbergena,c,* b c
Department of Cardiothoracic Surgery, Academic Medical Centre, Amsterdam, Netherlands Department of Cardiology Academic Medical Centre, Amsterdam, Netherlands Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
* Corresponding author. Department of Cardiothoracic Surgery, Academic Medical Centre, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. Tel: +31-205-66911; fax: +31-206-962289; e-mail: [email protected]; [email protected] (D.R. Koolbergen). Received 17 September 2014; received in revised form 20 November 2014; accepted 25 November 2014
Abstract OBJECTIVES: Valuable treatment modalities for branch pulmonary artery (BPA) stenoses are surgical patch angioplasty, percutaneous BPA stenting and hybrid stent placement. The purpose of this study was to report our institutional experience with hybrid stent placement to relieve BPA stenoses. METHODS: Between August 2007 and May 2014, 7 adults (5 females) with congenital heart disease (CHD) had elective intraoperative BPA stent placement. All 7 patients had undergone previous surgery [6 tetralogy of Fallot repairs and 1 arterial switch operation for transposition of the great arteries (TGAs)]. A total of 7 stents (4 right pulmonary artery, 3 left pulmonary artery) were implanted under direct vision, concomitant with a pulmonary homograft implantation (tetralogy of Fallot patients), or because percutaneous stenting was not feasible (TGA patient). Retrospective analysis of clinical data, procedural details and outcomes was performed. RESULTS: Overall, the mean age was 35 ± 7.2 years. Stent implantation was successful in all procedures. The mean postinflation stent diameter was 13.3 ± 2.0 mm. No stent migration, fracture, stent thrombosis, reintervention or deaths occurred. In 1 case the procedure was complicated by a right pulmonary artery tear just distal to the stent which was repaired by surgical patch angioplasty. At a mean follow-up of 55.6 ± 26 months no patient required catheter reintervention or surgery. Echocardiography (mean follow-up 47.1 ± 22 months), MRI (mean follow-up 43.8 ± 37 months) and CT data (mean follow-up 14.8 ± 10 months) demonstrate a BPA diameter increment from a mean 5.57 ± 2.29 to 10.71 ± 2.56 mm. CONCLUSIONS: Hybrid intraoperative BPA stent placement is safe and effective and can be used as an alternative for surgical patch angioplasty or if percutaneous BPA stenting is not feasible. Short- to mid-term results are good. Keywords: Congenital heart disease • Stent • Hybrid • Branch pulmonary artery
INTRODUCTION Branch pulmonary artery (BPA) stenosis is commonly associated with many congenital heart diseases (CHDs). Unilateral stenosis of one of the pulmonary artery (PA) branches causes a significant decrement of the PA branch flow and perfusion of the affected lung [1]. It can also potentially worsen pulmonary insufficiency in patients with repaired tetralogy of Fallot [2]. Surgical patch angioplasty and percutaneous BPA stenting are established treatment options for BPA stenosis [3, 4]. Percutaneous stenting is equally as effective as surgery in the treatment of BPA stenosis [5]. Surgical patch angioplasty can be a technically challenging procedure whereby stenosis commonly recurs due to compression on the patch from surrounding structures. However, percutaneous stenting is not always feasible due to right ventricular outflow
obstruction or difficult vascular access. After favourable results from intraoperative stenting of pulmonary arteries in small children [6], we recently described our first experiences with hybrid BPA stent placement in adult tetralogy of Fallot patients [7]. In our current study, the short and mid-term results of hybrid BPA stent placement are presented in an extended series of adult patients with CHD, including echocardiographic and radiographic followup with cardiac computerized tomography (CT) or cardiac magnetic resonance angiography (MRA).
MATERIALS AND METHODS A retrospective review of our surgical database of consecutive adult patients with CHD who underwent hybrid BPA stent
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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placement at our institution from August 2007 to May 2014 was performed. Retrospective analysis of clinical data, procedural details and outcomes was done.
The hybrid procedures The hybrid procedures combined both surgical and interventional techniques. All procedures were performed in a conventional cardiac operating theatre (OT) and on cardiopulmonary bypass (CPB). On a beating heart the pulmonary trunk was incised longitudinally and the PA branches were visualized directly (see Video 1). In the TGA patient a stent previously placed in the RPA was trimmed to free the way for the LPA stent placement. For inspection of the RPA stenosis following Waterston shunt, always directly behind and hidden by the ascending aorta, a prewarmed dental mirror was used. Positioning the mirror in the pulmonary confluence provided a clear view of the stenosis and then of the position and development of the stent. The length of the stent was selected on the basis of the vessel diameter as visualized by preoperative imaging by MRA or computerized tomography angiography, the location of the stenosis and intraoperative anatomical findings (see Fig. 1A and B). Bare Cheatham Platinum stents (NuMed, Inc., Hopkinton, New York, NY, USA) were implanted at all procedures. The Bare Cheatham Platinum stent was handcrimped on a SHYTAK II or Z-Med II balloon and placed over a guide wire across the lesion by the interventional cardiologist (see Video 1). The balloon was inflated in accordance with the manufacturer’s guidelines. When necessary, multiple balloon inflations were carried out to ensure full expansion of the stent. The stent was positioned under direct vision of the proximal part of the stent and the distal aspect was palpated digitally to ensure that the stent would not compromise the ostium of the upper lobe branch of the PA. Neither intraoperative fluoroscopy nor angiography were used. The proximal end of the stent was flared and it was then secured to the BPA wall by suture to prevent stent migration (see Video 1). At the end of surgery, intraoperative transoesophageal echocardiography was also utilized to confirm that the stent was appropriately positioned. Anticoagulant therapies used in the first 5 cases were aspirin and clopidrogel for 6 months; in Cases 6 and 7 clopidrogel therapy was reduced to 1 month. All patients had the follow-up echocardiograms and MRIs or CT scans. Outcome measures were procedural stent complications (stent malposition, stent fracture, stent migration/embolization or stent removal), BPA tear/rupture, diameter increment of the stenotic BPA segment and need for reintervention.
RESULTS During the study period, 7 adults (5 females) with CHD had elective intraoperative BPA stent placement. The mean age was 35 ± 7.2 years (see Table 1). All 7 patients had undergone cardiac surgery at an early age (6 total surgical repairs of tetralogy of Fallot and 1 arterial switch operation for TGAs). A total of 7 stents were implanted: 4 in the right pulmonary artery (RPA) and 3 in the left pulmonary artery (LPA). Concomitant surgical procedures performed were pulmonary homograft implantation (6 Fallot patients), tricuspid valve repair (2 Fallot patients) and surgical patch angioplasty (1 Fallot patient) (see Table 1). The RPA stent placements were done in patients previously treated with a Waterston shunt and total repair of tetralogy of Fallot. These patients had RPA stenoses at the previous anastomosis site of the Waterston shunt. Two Fallot patients had long segment stenosis of the LPA. The TGA patient had a left BPA stenosis not feasible for percutaneous stenting because of a previous stent in the RPA, partially covering the origin of the LPA. No concomitant procedure was performed in this patient. Procedures were completed successfully in all patients. The mean postinflation stent diameter was 13.3 ± 2.0 mm and the mean CPB time 117.4 ± 26.5 min. Aortic clamping was necessary in 2 cases. In 1 case it was necessary for repair of an RPA tear after stenting and in the other case because of the suboptimal exposition of the RPA ostium due to excessive collateral flow. Complications of initial stent placement (see Table 2) included the above-mentioned RPA tear, just distal to the stent, which was repaired by additional surgical patch angioplasty. In this case, 2 balloon inflations from 4 to 8 atmospheres to expand the Bare Cheatham Platinum stent in the RPA did not exceed the manufacturer’s guidelines. The postoperative course was uneventful in 6 patients. One patient developed a pneumothorax which was successfully managed with tube thoracostomy. The mean intensive care unit stay was 1.3 ± 0.5 days and the mean hospital stay was 7.7 ± 1.3 days. No mortality was associated with initial stent implantation. At the mean follow-up of 55.6 ± 26 months no patient required catheter reintervention or surgery. There were no cases of stent migration, stent fracture, stent thrombosis or reintervention. Echocardiography (mean follow-up 47.1 ± 22 months), MRA (mean follow-up 43.8 ± 37 months) and CT (mean follow-up 14.8 ± 10 months) data of 7 patients, demonstrated a BPA diameter increment from a mean 5.57 ± 2.29 to 10.71 ± 2.56 mm (see Fig. 1C). In 1 patient, a follow-up pulmonary angiogram was performed (see Fig. 1D). In 1 patient who for social reasons could not be followed up the first 7 years after the hybrid procedure, echocardiography and MRA findings were normal.
DISCUSSION
Video 1: Hybrid pulmonary stent placement in a stenotic left BPA. BPA: branch pulmonary artery.
Primary and secondary BPA stenoses are common problems in CHD. For example, in tetralogy of Fallot severe stenosis can develop at the site of a previously closed Waterston shunt in the RPA branch directly behind the aorta [7, 8]. Branch PA stenosis requires aggressive treatment to improve right ventricular pressure and to provide balanced pulmonary blood flow. Valuable treatment modalities for BPA stenoses are percutaneous stenting, surgical patch angioplasty and hybrid intraoperative stent placement. Endovascular stent placement for the treatment of BPA stenosis was introduced in 1991 [9].
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Figure 1: ( A) Preoperative CT angiogram demonstrating width measurement of the narrowed right pulmonary artery; (B) preoperative CT angiogram demonstrating length measurement from the ostium of the right pulmonary artery to the upper lobe branch; (C) the follow-up CT angiogram with a stent in the right pulmonary artery; (D) the follow-up pulmonary angiogram with a stent in the right pulmonary artery.
Table 1: Patient characteristics (n = 7) No
Sex
Age (years)
Weight (kg)
Previous surgery
Concomitant procedure
1 2 3 4
F F F F
38 41 39 21
70 79 103 60
PHG PHG PHG and angioplasty LPA No concomitant procedure
5 6 7
M M F
39 30 39
78 73 60
Repair TOF and Waterston shunt Repair TOF and Waterston shunt Repair TOF and Waterston shunt ASO, patch angioplasty RPA and LPA, percutaneous stent RPA and LPA Repair TOF and Waterston shunt Repair TOF Repair TOF
PHG and TVR PHG PHG and TVR
TOF: tetralogy of Fallot; PHG: pulmonary homograft; RPA: right pulmonary artery; LPA: left pulmonary artery; ASO: arterial switch operation; TVR: tricuspid valve repair.
Percutaneous stenting is an established treatment modality for BPA stenosis [10, 11], but early complications of percutaneous stenting are common [12]. In patients with CHD who have previously had surgery, surgical patch angioplasty for BPA stenosis may be challenging due to difficulty in accessing distal PA stenoses and the RPA behind the aorta, or in accessing complex stenoses with fibrosis, calcification or hypoplasia of the BPA. Difficult surgical access, bleeding and excessive collateral blood flow lead to longer duration of surgery, longer CPB time and the need for circulatory arrest.
Hybrid intraoperative stent placement is an optional treatment for BPA stenosis in the following situations: (i) percutaneous stenting is difficult or impossible because of limited vascular access or complex anatomy; (ii) as surgery concomitant with other surgical procedures and if surgical patch angioplasty is not feasible [13, 14]; (iii) as rescue treatment following complications of percutaneous stenting [12, 15, 16]. At our centre, 58% of the total number of patients receiving pulmonary stents or surgical patch angioplasty had undergone hybrid intraoperative stent placement. Also, 6 previously operated
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Table 2: Details of the procedure and follow-up No
Stent position
Stent Ø (mm)
Complications
Follow-up investigations
Follow-up (months)
1 2 3 4 5 6
RPA RPA RPA LPA RPA LPA
14 12 15 12 15 10
No No Rupture RPA No No No
84 39 85 33 80 38
7
LPA
15
No
Echocardiography, MRA Echocardiography, MRA Echocardiography, MRA Echocardiography, MRA, CT Echocardiography, MRA, CT angiography Echocardiography, CT angiography, Pulmonary angiography Echocardiography, MRA, CT
30
RPA: right pulmonary artery; LPA: left pulmonary artery; Ø: diameter; CT: computerized tomography; MRA: magnetic resonance angiography.
tetralogy of Fallot patients needed treatment for BPA stenosis concomitant with pulmonary homograft implantation. The indications for performing hybrid intraoperative stent placement in these patients were (i) to lower the level of complexity of reoperations without performing additional surgical patch angioplasty, (ii) to shorten the surgical procedure and CPB time by lowering the level of difficulty of BPA dissection and access due to adhesions, scarring or bleeding, (iii) to be able to reach poorly accessible anatomical sites for surgical patch angioplasty such as an RPA behind the aorta or a long segment LPA stenosis with adhesions after previous surgery and (iv) to reduce the risk of restenosis following surgical patch angioplasty (due to compression from surrounding structures). The TGA patient needed hybrid intraoperative stent placement for BPA stenosis but no concomitant surgery. The indication was a left BPA stenosis unsuitable for percutaneous stent placement due to previous stent placement in the RPA, partially covering the origin of the LPA. Complications associated with hybrid intraoperative stent placement are (i) PA dissection or tear, (ii) stent migration, (iii) incomplete expansion of stent, (iv) stent thrombosis, (v) obstruction of smaller PA branches, (vi) in-stent restenosis, (vii) inhibition of PA growth and (viii) transient pulmonary oedema [17–21]. In our cohort, 1 of 7 (14%) patients needed surgical patch angioplasty intervention for an RPA tear. This could be explained by circumferential surgical dissection of the RPA prior to stent placement. The presence of scar tissue around the BPA may be of benefit in hybrid intraoperative stent placement by providing support during stent expansion and thereby preventing BPA tears [16, 22– 24]. Angtuaco et al. [22] reported 5 of 67 (7%) patients with BPA tears as the initial complication of hybrid stent placement. Ungerleider et al. [14] reported 2 of 27 (7%) patients with BPA tears and Mitropoulos et al. [24] experienced no perioperative morbidity during intraoperative stent placement. To prevent tear or rupture during intraoperative stent placement, extensive surgical dissection of the BPA and balloon over-inflation, i.e. exceeding manufacturer’s guidelines, should be avoided. Hybrid intraoperative stent placement has some important advantages: (i) control of vascular ruptures; (ii) prevention of stent migration; (iii) shortening of CPB time or clamp time; (iv) avoiding the need to transect the ascending aorta for patch angioplasty of the RPA; and (v) support for a repaired BPA, thus preventing collapse. In all our cases, direct vision, the use of a dental mirror and digital palpation were sufficient to achieve accurate stent positioning and placement, thus making fluoroscopy or angiography unnecessary and the procedure achievable in any conventional cardiac OT. Stent migration can be prevented by accurate stent
placement across the stenotic BPA, flaring the proximal end of the stent and suturing it to the BPA wall. In our study, during a mean follow-up of 55.6 ± 26 months there were no cases of stent thrombosis or in-stent restenosis. Echocardiography, MRA and CT follow-up data were satisfactory, showing a diameter increment of at least 40%, with a theoretical exponential increase in orifice area. Still, longer-term results have to be awaited. It is clear that close collaboration between cardiac surgeons and interventional cardiologists is essential in this hybrid management strategy. The constantly growing population of adults with a history of surgery for congenital heart defects means that more indications for hybrid BPA stent placement can be expected in a broad spectrum of diagnoses such as pulmonary atresia, truncus arteriosus and all cases where pulmonary arteries have previously been surgically or interventionally addressed. In conclusion, hybrid intraoperative BPA stent placement is a safe and effective technique that can be used as an alternative to surgical patch angioplasty, or in cases where percutaneous BPA stenting is not feasible in patients with CHD undergoing cardiac reoperations. It can be safely performed without fluoroscopy. Short- to mid-term results are excellent. Conflict of interest: none declared.
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ORIGINAL ARTICLE
W. Lynch et al. / Interactive CardioVascular and Thoracic Surgery
