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Hybrid Approach: Stent Implantation

  • Ralf J. HolzerEmail author
  • Jeffrey Dayton
Chapter
  • 480 Downloads

Abstract

Stent delivery using a hybrid approach is a type of procedure that utilizes both surgical and interventional techniques to combine the advantages of each approach. Hybrid procedures have increased in frequency over the last two decades and are performed by the majority of congenital cardiac centers, as documented by a CCISC survey conducted by Dan Gruenstein in 2013. Intraoperative stents have been placed in a variety of locations, even though pulmonary arteries are the most common destination for this therapy.

Supplementary material

Video 1a

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (a) Baseline angiography through the sidearm of the sheath, documenting the shunt to measure 2–2.5 mm in diameter with an additional proximal and minor distal narrowing. Prior to entering the shunt, a decision was made to use two coaxial coronary stents (an 18 mm × 4 mm Multilink Vision as well as a 15 mm × 4 mm Multilink Vision). It is crucial to have those stents ready to go in case more profound desaturations are encountered when crossing the shunt (MOV 67 kb)

Video 1b

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (b) A 014″ choice PT wire is advanced through the sheath and shunt into the right pulmonary artery and wire position confirmed using a hand injection through the sidearm of the hemostatic sheath. (MOV 206 kb)

Video 1c

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (c) Subsequently the 18 mm × 4 mm Multilink Vision stent is advanced though the shunt using repeated small hand injections to confirm the position (MOV 257 kb)

Video 1d

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (d) Once appropriate position is confirmed, the stent is expanded in a controlled manner (MOV 1548 kb)

Video 1e

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (e) After stent expansion, an angiography is performed through the sidearm of the sheath to confirm adequate stent position as well as a lack of any vascular injury (MOV 237 kb)

Video 1f

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (f) Subsequently the 14 mm × 4 mm Multilink Vision stent is advanced though the shunt coaxial into the previous stent using repeated small hand injections to confirm the position (MOV 184 kb)

Video 1g

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (g) Once appropriate position is confirmed, the second stent is expanded in a controlled manner (MOV 1556 kb)

Video 1h

Five-month-old infant with tetralogy of Fallot that has previously undergone placement of a 3.5 mm right modified Blalock-Taussig shunt (RMBTS) and presented with desaturations into the 60th. The infant had previously developed femoral artery occlusion after cardiac catheterization, and therefore it was felt that a direct approach using carotid cutdown was the best approach for this patient. Right carotid cutdown was performed and a 6Fr sheath inserted. (h) After expansion of the second stent, a final angiography is performed through the sidearm of the sheath to confirm adequate stent position as well as a lack of any vascular injury (MOV 254 kb)

Video 2a

Five-month-old infant with hypoplastic left heart syndrome undergoing comprehensive stage II palliation. Exit angiography revealed lack of flow to the left pulmonary artery, and therefore intraoperative hybrid stent placement using a direct approach under angiographic guidance was recommended (videos from Dr. John Cheatham, Nationwide Children’s Hospital, Columbus, OH). (a) Initially a Berman angiographic catheter is inserted through a purse string into the superior caval vein and an angiography performed, which in this case documented lack of flow to the left pulmonary artery (MP4 10900 kb)

Video 2b

Five-month-old infant with hypoplastic left heart syndrome undergoing comprehensive stage II palliation. Exit angiography revealed lack of flow to the left pulmonary artery, and therefore intraoperative hybrid stent placement using a direct approach under angiographic guidance was recommended (videos from Dr. John Cheatham, Nationwide Children’s Hospital, Columbus, OH). (b) To obtain more distal landmarks and size of the vessel, the catheter is further advanced carefully into the left pulmonary artery and an angiography repeated in distal position. This is then followed by advancing a short 7Fr sheath into the SVC. It is often difficult to advance the sheath into a distal LPA position, and therefore frequently the balloon-mounted (19 mm Genesis XD) stent is carefully advanced directly into the LPA without the use of sheath cover. This has the advantage of not distorting the anatomy once the stent has been placed in LPA position. It helps gently inflating the balloon to cover the sharp edges of the stent (MP4 5834 kb)

Video 2c

Five-month-old infant with hypoplastic left heart syndrome undergoing comprehensive stage II palliation. Exit angiography revealed lack of flow to the left pulmonary artery, and therefore intraoperative hybrid stent placement using a direct approach under angiographic guidance was recommended (videos from Dr. John Cheatham, Nationwide Children’s Hospital, Columbus, OH). (c) The stent is then expanded under fluoroscopic guidance and a final angiography performed as a hand injection through the sidearm of the sheath, documenting appropriate stent position without any vascular injury. There was minor jailing of the left upper lobe branch (MP4 4568 kb)

Video 3

Video complementing the still images (Fig. 31.2) in an adult patient with status post repair of tetralogy of Fallot with a proximal left pulmonary artery (LPA) stenosis (kink) who underwent for intraoperative stent placement (under direct vision) at the same time. The video documents the initial evaluation of the pulmonary artery anatomy and side branch location, followed by documentation of the result after stent implantation (MOV 7065 kb)

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Professor of Clinical Pediatrics Division Chief Pediatric Cardiology, Director Pediatric Cardiac CatheterizationWeill Cornell Medicine, NewYork-Presbyterian Komansky Children’s Hospital,New YorkUSA
  2. 2.Assistant Professor Clinical PediatricsWeill Cornell Medicine, NewYork-Presbyterian Komansky Children’s HospitalNew YorkUSA

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