Airway compression: a rare but serious complication following stenting of the patent ductus arteriosus

Introduction

In 1992 Gibbs et al. described successful stenting of the patent ductus arteriosus (PDA) in two neonates with complex pulmonary atresia [1]. Since then the procedure has increasingly been performed in preference to the modified Blalock-Taussig shunt (mBTS) with potential advantages of avoiding cardiac surgery in the neonatal period and stimulating better and more symmetrical pulmonary arterial growth [2–5]. Variations in the site of ductal origin, insertion, shape and tortuosity lead to an unpredictable array of ductal morphologies, with complex duct-airway interactions which are poorly understood [6]. In this report we describe two such scenarios wherein PDA stenting led to severe airway obstruction and required removal of the stent.

Case studies

Case 1 – baby A

A 2-week-old boy (weight 3.7 kg) with an antenatal diagnosis of right atrial isomerism, unbalanced atrioventricular septal defect, supracardiac total anomalous pulmonary venous drainage and pulmonary atresia was stable on the ward with prostaglandin infusion maintaining ductal patency. Computed tomography (CT) of the thorax showed a right-sided aortic arch with the duct in close proximity to the left main bronchus. The pulmonary arteries were confluent (left pulmonary artery (LPA) 5.5 mm, right pulmonary artery (RPA) 4.5 mm) and supplied by a long straight duct originating from the base of the left innominate artery, inserting towards the left pulmonary artery.
PDA stenting was performed under general anaesthesia via the right femoral artery. The PDA was crossed with a 014” BMW and 014” Thruway wire with resulting ductal spasm and desaturation leading to instability. A 4.5 × 24 mm Liberté stent (Boston Scientific, Natick, Massachusetts) was deployed at the PA end to restore pulmonary blood flow. A second 4.5 × 20 mm Liberté stent was then deployed to cover the aortic end. There was some migration of the first stent towards the PA; hence a third 4.5 × 16 mm Liberté stent was required to overlap the stents. The final angiogram showed good flow to both pulmonary arteries. Though there was some protrusion there was good flow in the innominate artery. The procedure time and fluoroscopy times were 75 and 17 min respectively. Post-procedure saturations were 85%. He developed necrotising enterocolitis which was medically managed and he was subsequently discharged home 16 days after the procedure on antiplatelet therapy. Due to recurrent...


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