Challenges in neonatal ductal stenting: When to avoid tortuous ducts and pulmonary artery stenosis

Ductal stenting (DS) is the preferred palliative approach to the Blalock-Thomas-Taussig shunt (BTTS) for neonates with duct-dependent pulmonary circulation. However, appropriate case selection remains a critical challenge. This report explores the limitations of DS through illustrative examples and defines the subset in which neonatal DS is better avoided. Tortuous ducts increase the risk of procedural failure, ductal spasm, and pulmonary artery (PA) jailing. These can generally be managed with wire techniques and stiff wires. If extreme curvature persists despite these measures, it is best to abandon the procedure. Bilateral PA stenosis needs careful strategic planning and is often better managed surgically. Procedural risk is significantly high when both branch PA stenosis and tortuosity coexist, necessitating a BTTS. This pictorial report specifies anatomical substrates that are unsuitable for neonatal DS to improve safety and efficacy. It is intended as a visual reference for interventionists facing comparable clinical scenarios, particularly in early career.