Editorial Comment

Shunting in the Right Direction:The Not So Hidden Truth

Neil Wilson,* MD

John Radcliffe Hospital, Paediatric Cardiology,Oxford, Oxfordshire, United Kingdom

Twenty years on Gibbs should be justly proud of hispioneering approach to transcatheter palliation of stent-ing the arterial duct, despite his somewhat negative butentirely justified conclusions on the medium term resultsof his efforts [1,2]. The procedure that has endured isa testament to the unpublicized poor outcome of patientsundergoing surgical systemic to pulmonary artery shunts.A look at the publicly accessible online validatedNational UK database of congenital cardiac surgery andintervention [3] tells us why Kenny and his colleaguescontinue to develop improvements in transcatheter/hybrid delivery of stents in the arterial duct. Ask your-selves, ‘‘What is the mortality outcome at 30 days and1 year of patients in our hospital who undergo a systemicto pulmonary shunt?’’ 5%, maybe? 10% maximum?Wrong! In the most recent epoch 2008–2009, of allpatients undergoing a surgical systemic to pulmonaryshunt, mortality is 12.6% at 30 days and a sobering33.3% at 1 year. To me, it would be bordering on theneglectful NOT to be looking at ways of bettering theoutlook for such patients, particularly if one stratifiedrisk in the way the authors of this article demonstrate.Another subtle point made by Kenny is the concept ofopening the duct even when it is completely closed.Good logic there. It is difficult (though not impossible)to make matters worse by opening something that isalready completely occluded. As the author points out, aduct widely patent with prostaglandin can pose problems

for stenting by being the only source of pulmonaryblood flow, being rather too wide in caliber for favoredcoronary artery stents and being relatively friable.Revascularization of a duct which is completely closedis relatively safe: it means that there are other sources ofpulmonary blood flow keeping the patient alive, and thatstent positioning is likely to be stable.In some ways Kenny and colleagues are extending

the concepts propagated by Holzer and Galantowiczand colleagues who are in the forefront of hybrid tech-niques worldwide and who used different vascular andhybrid approaches to palliate pulmonary vascularobstruction using stent angioplasty [4]. Femoral arteryapproaches are not the only, and often not the bestway to approach the arterial duct. Femoral artery andvein, carotid and axillary artery and hepatic vein mayall come into play percutaneously when the site, size,direction, and tortuosity of the duct dictate. That sur-geons like Galantowicz are willing to cooperate andperhaps even drive the hybrid access approach to ductstenting is true progress and can only help reduce themortality and outcome of this difficult group of neo-nates. We will find out.

REFERENCES

1. Gibbs JL, Rothman MT, Rees MR, Parsons JM, Blackburn ME,

Ruiz CE. Stenting of the arterial duct: A new approach to pallia-

tion for pulmonary atresia. Br Heart J 1992;67:240–245.

2. Gibbs JL, Uzun O, Blackburn ME, Wren C, Hamilton JR,

Watterson KG. Fate of the stented arterial duct. Circulation 1999;

99:2621–265.

3. www.ccad.org.uk/002/congenital. Online public access validated

database of congenital cardiac surgery and interventions in the

United Kingdom. Accessed November 2011.

4. Holzer RJ, Chisolm JL, Hill SL, Phillips A, Cheatham JP, Galan-

towicz M. Hybrid stent delivery in the pulmonary circulation.

J Invasive Cardiol 2008;11:592–598.

Conflict of interest: Nothing to report.

*Correspondence to: Neil Wilson, John Radcliffe Hospital, Paediatric

Cardiology, Oxford, Oxfordshire, United Kingdom.

E-mail: Neilwil1@aol.com

Received 15 November 2011; Revision accepted 15 November 2011

DOI 10.1002/ccd.23480

Published online 16 December 2011 in Wiley Online Library

(wileyonlinelibrary.com).

' 2011 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 79:131 (2012)