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Venous Access Alone Versus Arterial and Venous Access for Patent Arterial Duct Device Closure in Childhood
Ahmed A Hassan1, Marisa Signorile2, Sophie McNamee1
1Department of Pediatrics, Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children, Temertry Faculty of Medicine, University of Toronto, Toronto, Canada.
Insights
A venous-only (VA) strategy for arterial duct closure in children significantly reduces radiation exposure and procedure times compared to the standard arterial-venous approach (AA). This approach is safe and effective, leading to shorter recovery times and fewer hospital admissions.
Area of Science:
- Pediatric Cardiology
- Interventional Cardiology
- Congenital Heart Disease
Background:
- Patent ductus arteriosus (PDA) is a common congenital heart defect, potentially leading to heart failure and pulmonary hypertension.
- Percutaneous device closure is the standard treatment, typically involving both arterial and venous access (AA).
- A venous-only access (VA) strategy offers a potential alternative to minimize invasiveness.
Purpose of the Study:
- To compare the efficacy and safety of a venous-only (VA) access strategy versus the standard arterial-venous (AA) access for percutaneous closure of PDA in children.
- To evaluate if VA reduces procedure time, radiation exposure, and contrast volume compared to AA.
Main Methods:
- Retrospective cohort study of 405 children undergoing isolated PDA device closure between 2011 and 2022.
- Children were categorized into VA or AA groups based on initial access.
- Outcomes analyzed included radiation dose (DAP), fluoroscopy time, contrast volume, procedure duration, and length of stay (LOS).
Main Results:
- The VA group (n=106) showed significantly lower dose area product (DAP), fluoroscopy times, contrast volumes, procedure times, and recovery room LOS compared to the AA group.
- Fewer children in the VA group required hospital admission (5.7% vs. 14.7%).
- Conversion to AA was needed in 13.2% of VA cases for complex anatomy, but no significant difference in reintervention rates was observed between groups.
Conclusions:
- Venous-only access for PDA device closure is associated with reduced radiation exposure (DAP) and shorter recovery room LOS.
- The VA strategy demonstrates procedural safety, with a lower likelihood of admission and no difference in reintervention rates.
- VA should be considered a preferred approach for eligible pediatric PDA cases.
Background:
The persistently patent arterial duct accounts for ~12% of congenital heart lesions. Untreated, it may result in heart failure due to volume loading of the left heart, pulmonary hypertension, and infective endarteritis. Percutaneous device closure is the preferred occlusion technique, with the standard approach consisting of femoral artery access for angiography and venous access for device delivery (AA). A venous-only strategy (VA) for angiography and device delivery can also be employed.
Hypothesis:
We hypothesized that VA would eliminate the need of arterial entry, reduce procedure times and radiation exposure compared to standard AA.
Methods:
This is a retrospective cohort study of isolated arterial duct device closure at the Hospital for Sick Children from January 1, 2011, through December 31, 2022. Exclusions included premature neonates, children requiring arterial access for monitoring, and those who underwent other procedures. Children were categorized based upon initial access determined by operator preference into VA or AA groups.
Results:
The cohort consisted of 405 children, 252 (62.2%) females, with a median age of 3.1 years (IQR 1.30-5.84), median weight 13.2 kg (IQR 9.0-19.5), and duct diameter of 2.9 mm (IQR 2.0-3.5) with no significant differences between the groups. Type A ducts were more frequent in the AA group (90% vs. 72%). The VA group included 106 children, of which 14 (13.2%) required AA conversion for angiography due to complex ductal anatomy, to assess device position before release, but remained in the VA group for analysis. Children in the VA group had lower dose area product (DAP) (p < 0.001), fluoroscopy times (p = 0.025), contrast volumes (p < 0.001), procedure times (p < 0.001), and recovery room lengths of stay (LOS) (p < 0.001). Six (5.7%) VA children required admission compared to 44 (14.7%) in the AA group (p = 0.015) with no difference in reintervention rates. Weighted regression analysis showed VA was associated with reduced admission likelihood (OR: 0.354 [0.131, 0.822], p = 0.024), DAP (coef -126.4 [-213.3, -39.4], p = 0.004), and contrast volumes (coef 31.2 [-36.6, -25.9], p < 0.001) compared to AA.
Conclusions:
Venous-only access was associated with lower DAP and recovery room LOS. Additionally, VA was associated with a lower likelihood of admission with no difference in reintervention rates, suggesting procedural safety. These findings support the consideration of VA as a preferred approach for appropriate cases.
