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Advances in Pediatric Ductal Intervention: an Open or Shut Case?

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Purpose of Review

To review the most recent literature on pediatric transcatheter ductal intervention including ductus arteriosus occlusion and stenting.

Recent Findings

With the development and FDA approval of smaller ductal devices, including most recently the Amplatzer Piccolo Occluder (Abbott, Abbott Park, IL), transcatheter ductus arteriosus device closure is now being safely performed in premature infants and patients < 6 kg using a transvenous approach. In patients with ductus-dependent pulmonary blood flow, ductal stenting with pre-mounted coronary artery stents has been shown to be an acceptable alternative to the surgically placed Blalock-Taussig shunt. Centers with experience in ductal stenting have demonstrated success, even with the tortuous ductus.


Innovation in transcatheter device technology and procedural practices have allowed for significant advances. Transcatheter ductal device closure is a reasonable alternative to surgical ligation even in premature, low-birthweight infants. Ductal stenting is also an accepted alternative to the modified Blalock-Taussig shunt. We anticipate continued advancement and procedural refinement over the next several years.

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Feltes TF, Bacha E, Beekman RH 3rd, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation. 2011;123(22):2607–52.

  2. 2.

    El-said HG, Bratincsak A, Foerster SR, Murphy JJ, Vincent J, Holzer R, et al. Safety of percutaneous patent ductus arteriosus closure: an unselected multicenter population experience. J Am Heart Assoc. 2013;2(6):e000424.

  3. 3.

    Petrucci O, O’Brien SM, Jacobs ML, Jacobs JP, Manning PB, Eghtesady P. Risk factors for mortality and morbidity after the neonatal Blalock-Taussig shunt procedure. Ann Thorac Surg. 2011;92(2):642–51; discussion 651–2.

  4. 4.

    •• Glatz AC, Petit CJ, Goldstein BH, et al. A 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. 2018;137(6):589–601. This multicenter retrospective review of patients who underwent either PDA stent or Blalock-Taussig shunt for ductus-dependent pulmonary blood flow demonstrated no difference in death or unplanned reintervention rates. A shorter ICU length of stay, lower procedural complication rate, and larger and more symmetric pulmonary arteries were found in the PDA stent group.

  5. 5.

    Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent ductus arteriosus: 62 cases treated without thoracotomy. Radiol Clin N Am. 1971;9(2):203–18.

  6. 6.

    Rashkind WJ, Cuaso CC. Transcatheter closure of a patent ductus arteriosus: successful use in a 3.5 kg infant. Pediatr Cardiol. 1979;1:3–7.

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    Rashkind WJ. Therapeutic interventional procedures in congenital heart disease. Radiol Diagn (Berl). 1987;28:449–60.

  8. 8.

    Lloyd TR, Beekman RH, Moore JW, Hijazi ZM, Hellenbrand WE, Sommer RJ, Wiggins JW, Zamora R, Vincent RN; for the PDA Coil Registry Investigators. The PDA Coil Registry: report of the first 535 procedures.

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    Pass RH, Hijzi Z, Hsu DT, Lewis V, Hellenbrand WE. Multicenter USA Amplatzer Patent Ductus Arteriosus Occlusion Device Trial: initial and one-year results. J Am Coll Cardiol. 2004;44(3):513–9.

  10. 10.

    Krichenko A, Benson LN, Burrows P, et al. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol. 1989;63(12):877–80.

  11. 11.

    • Philip R, Rush Waller B III, Agrawal V, Wright D, Arevalo A, Zurakowski D, et al. Morphologic characterization of the patent ductus arteriosus in the premature infant and the choice of transcatheter occlusion device. Catheter Cardiovasc Interv. 2015;87:310–7. The authors describe a fetal type or type F ductus arteriosus as an addition to the classic A–E Krichenko classification. This duct morphology is commonly found in premature infants.

  12. 12.

    • Backes CH, Kennedy KF, Locke M, et al. Transcatheter occlusion of the patent ductus arteriosus in 747 infants <6 kg: insights from the NCDR IMPACT Registry. JACC Cardiovasc Interv. 2017;10(17):1729–37. Findings from this multicenter study found that transcatheter PDA occlusion in infants less than 6 kg is technically feasible. Major adverse events including arterial injury and device embolization are more common in infants less than 30 days old and of extremely low weight (< 2 kg).

  13. 13.

    • Backes CH, Rivera BK, Bridge JA, et al. Percutaneous patent ductus arteriosus (PDA) closure during infancy: a meta-analysis. Pediatrics. 2017;139(2):e20162927. This meta-analysis includes 38 studies with a technical success rate of 92.2% with a clinically significant adverse event incidence of 10.1%. Lack of standardized adverse event reporting limits the interpretation.

  14. 14.

    Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol. 2012;36(2):123–9.

  15. 15.

    Noori S, Mccoy M, Friedlich P, et al. Failure of ductus arteriosus closure is associated with increased mortality in preterm infants. Pediatrics. 2009;123(1):e138–44.

  16. 16.

    Haneda N, Masue M, Tasaka M, Fukui C, Saito K, Yamaguchi S. Transcatheter closure of patent ductus arteriosus in an infant weighing 1180 g. Pediatr Int. 2001;43(2):176–8.

  17. 17.

    Bentham J, Meur S, Hudsmith L, Archer N, Wilson N. Echocardiographically guided catheter closure of arterial ducts in small preterm infants on the neonatal intensive care unit. Catheter Cardiovasc Interv. 2010;77(3):409–15.

  18. 18.

    •• Zahn EM, Peck D, Phillips A, et al. Transcatheter closure of patent ductus arteriosus in extremely premature newborns: early results and midterm follow-up. JACC Cardiovasc Interv. 2016;9(23):2429–37 The authors review outcomes for extremely premature infants who underwent transcatheter echocardiographically guided PDA closure. The success rate was 88% with no procedural deaths or device embolizations.

  19. 19.

    • Sathanandam S, Justino H, Waller BR 3rd, Radtke W, Qureshi AM. Initial clinical experience with the Medtronic Micro Vascular Plug™ in transcatheter occlusion of PDAs in extremely premature infants. Catheter Cardiovasc Interv. 2017;89(6):1051–8. The authors describe a multicenter experience using the Medtronic Micro Vascular Plug in 15 premature infants with a median weight of 1210 g. The successful occlusion rate was 93% with no complications related to the procedure.

  20. 20.

    •• Sathanandam S, Balduf K, Chilakala S, Washington K, Allen K, Knott-Craig C, et al. Role of transcatheter patent ductus arteriosus closure in extremely low birth weight infants. Catheter Cardiovasc Interv. 2019;93(1):89–96. This study compares outcomes between surgical ductal ligation and transcatheter PDA closure in extremely low-birthweight infants. The findings demonstrate that transcatheter PDA closure may be associated with faster weaning of respiratory support post-procedure.

  21. 21.

    Baspinar O, Sahin DA, Sulu A, Irdem A, Gokaslan G, Sivasli E, et al. Transcatheter closure of patent ductus arteriosus in under 6 kg and premature infants. J Interv Cardiol. 2015;28(2):180–9.

  22. 22.

    Gibbs JL, Rothman MT, Rees MR, Parsons JM, Blackburn ME, Ruiz CE. Stenting of the arterial duct: a new approach to palliation for pulmonary atresia. Br Heart J. 1992;67:240–5.

  23. 23.

    • Qureshi AM, Goldstein BH, Glatz AC, et al. 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. 2019;93(5):933–43. The authors propose a new classification for ductal morphology in patients with ductus-dependent pulmonary blood flow based on the tortuosity of the vessel. A higher tortuosity index was associated with pulmonary artery jailing and unplanned reintervention, but pulmonary artery jailing did not affect pulmonary artery size at follow-up.

  24. 24.

    •• Bentham JR, Zava NK, Harrison WJ, et al. 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. 2018;137(6):589–601. The authors compare post-procedural outcomes between patients who underwent a modified Blalock-Taussig shunt or a ductal stent. The findings demonstrate a discharge survival advantage for patients in the ductal stent group. Long-term outcomes show a reduced risk of death prior to repair in the ductal stent group, but the reintervention rate was slightly higher.

  25. 25.

    Aggarwal V, Petit CJ, Glatz AC, Goldstein BH, Qureshi AM. Stenting of the ductus arteriosus for ductal dependent pulmonary blood flow—current techniques and procedural considerations. Congenit Heart Dis. 2019;14:110–5.

  26. 26.

    Rehman R, Marhisham MC, Alwi M. Stenting the complex patent ductus arteriosus in tetralogy of Fallot with pulmonary atresia: challenges and outcomes. Futur Cardiol. 2018;14(1):55–73.

  27. 27.

    Celebi A, Yucel IK, Bulut MO, Kucuk M, Balli S. Stenting of the ductus arteriosus in infants with functionally univentricular heart disease and ductal-dependent pulmonary blood flow: a single-center experience. Catheter Cardiovasc Interv. 2017;89(4):699–708.

  28. 28.

    Santoro G, Gaio G, Giugno L, Capogrosso C, Palladino MT, Iacono C, et al. Ten-years, single-center experience with arterial duct stenting in duct-dependent pulmonary circulation: early results, learning-curve changes, and mid-term outcome. Catheter Cardiovasc Interv. 2015;86(2):249–57.

  29. 29.

    Udink Ten Cate FE, Sreeram N, Hamza H, Agha H, Rosenthal E, Qureshi SA. Stenting the arterial duct in neonates and infants with congenital heart disease and duct-dependent pulmonary blood flow: a multicenter experience of an evolving therapy over 18 years. Catheter Cardiovasc Interv. 2013;82(3):E233–43.

  30. 30.

    Justino H, Petit CJ. Percutaneous common carotid artery access for pediatric interventional cardiac catheterization. Circulation: Cardiovasc Interv. 2016;9(4):e003003.

  31. 31.

    Choudhry S, Balzer D, Murphy J, Nicolas R, Shahanavaz S. Percutaneous carotid artery access in infants < 3 months of age. Catheter Cardiovasc Interv. 2016;87(4):757–61.

  32. 32.

    Polat TB. Stenting the vertical ductus arteriosus via axillary artery access using “wire-target” technique. Congenital Heart Dis. 2017;12(6):800–7.

  33. 33.

    • Lee J, Ratnayaka K, Moore J, El-Said H. Stenting the vertical neonatal ductus arteriosus via the percutaneous axillary approach. Congenital Heart Dis. 2019. The authors provide a brief series of patients with vertical ducts who underwent ductal stenting via the axillary artery approach. No procedural mortality or complications were reported.

  34. 34.

    • Breatnach CR, Aggarwal V, Al-Alawi K, CJ MM, Franklin O, Prendiville T, et al. Percutaneous axillary artery approach for ductal stenting in critical right ventricular outflow tract lesions in the neonatal period. Catheter Cardiovasc Interv. 2019;93(7):1329–35. The authors describe the axillary artery approach as a viable option for ductal stenting in neonates with ductus-dependent pulmonary blood flow. Three access-related complications were reported with no long-term sequelae.

  35. 35.

    Lee KJ, Seto W, Benson L, Chaturvedi RR. Pharmacokinetics of sirolimus-eluting stents implanted in the neonatal arterial duct. Circ Cardiovasc Interv. 2015;8(5).

  36. 36.

    • Aggarwal V, Dhillon GS, Penny DJ, Gowda ST, Qureshi AM. Drug eluting stents compared to bare metal stents for stenting the ductus arteriosus in infants with ductal dependent pulmonary blood flow. Am J Cardiol. 2019;124(6):952–9. The findings suggest that infants undergoing ductal stenting for ductus-dependent pulmonary blood flow with a drug-eluting stent as opposed to a bare-metal stent have decreased luminal loss and lower unplanned reintervention rates.

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Correspondence to Athar M. Qureshi.

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Lindsay Eilers declares no conflict of interest.

Athar M. Qureshi reports personal fees from W. L. Gore and Associates, and from Edwards Lifesciences.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Eilers, L., Qureshi, A.M. Advances in Pediatric Ductal Intervention: an Open or Shut Case?. Curr Cardiol Rep 22, 14 (2020).

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  • Congenital heart disease
  • Ductus-dependent pulmonary blood flow
  • Ductus arteriosus
  • Stent
  • PDA device