Catheterization and Cardiovascular Interventions 77:390–394 (2011)
The Outcome of Pulmonary Artery Stents Following Surgical Manipulation Mark A. Law,1
MD,
John P. Breinholt III,2 MD, Pirouz Shamszad,3 MD, Henri Justino,3 Charles E. Mullins,3 MD, and Frank F. Ing,3 MD
MD,
Background: Pulmonary artery (PA) stents are utilized to treat branch pulmonary stenosis (BPS). Often patients with PA stents undergo subsequent cardiac surgery for other indications, and the stents can be manipulated during the procedure. Objective: The purpose of this study was to evaluate the outcome of branch PA stenoses following surgical manipulation of previously implanted PA stents and to determine factors associated with future reintervention. Methods: Catheterization data, operative reports, and clinical summaries were reviewed on patients with PA stents placed between September 1989 and December 2006 undergoing subsequent cardiac surgery. Surgical manipulation was recorded as removed, trimmed, or longitudinally transected, and patched. Those that were not manipulated were defined as untouched. Results: 459 patients had branch PA stents placed. About 54 patients, with 70 stents in branch PA’s. subsequently had further cardiac surgery. The median age of stent placement was 7.5 (0.5–32.4) years with a median age of surgery of 12.7 (5.1–39.6) years. Surgical manipulation was performed in 23 (33%) PA’s and 47 (66%) stents were untouched. Stent removal occurred in 11 (16%), with transecting longitudinally and patching in 5 (7%), and trimming in 7 (10%). Comparing the surgical manipulation and the untouched groups, there was no difference in median age of stent placement [7.2 (0.5–30.2) versus 7.6 (1.8–32.4) years, p 5 0.40], wt [21.0 (5.3–86.5) versus 24.7 (9.0–96.0) kg, p 5 0.42], or residual catheterization gradient across the stent [3 (0–59) versus 4 (0–50) mmHg, p 5 0.81]. Catheter reintervention (stent n 5 6 or balloon dilation n 5 14) on the previously stented PAs was similar between the surgically manipulated (median 7.5 years) and untouched groups (median 11.5 years) (p 5 0.31). In multivariate analysis, the factors associated with future catheter reintervention were having the stent transected longitudinally and patched (p 5 0.003) and a lower weight (p 5 0.006) at the time of stent placement. Conclusions: Surgical stent manipulation is often performed in patients who have PA stents. Surgical manipulation does not alter the need for future reintervention and catheter re-intervention may be more likely when the stents are transected longitudinally and patched. VC 2010 Wiley-Liss, Inc. Key words: pediatric Interventions; pulmonary angiography; right ventricle; congenital heart disease in adults
INTRODUCTION
Branch pulmonary artery (PA) stenosis is a common associated finding in many congenital heart diseases, for example, tetralogy of Fallot. Branch PA stent placement was first reported in humans in 1991, with excellent short-term and midterm results [1–7], and this has become the standard of care for the treatment 1
Division of Pediatric Cardiogy, The University of Alabama at Birmingham, Birmingham, Alabama 2 Division of Pediatric Cardiology, Indiana University School of Medicine, Indianapolis, Indiana 3 Department of Pediatrics, Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas Conflict of interest: The authors have no conflict of interest. C 2010 Wiley-Liss, Inc. V
of branch PA stenosis to improve right ventricular pressure [1–7], pulmonary blood flow differentials [2,8], and potentially diminish the deleterious effects of pulmonary insufficiency that is often associated [9]. Many patients, who have had branch PA stents in place, require subsequent cardiac surgical interventions such as placement or replacement of right ventricular to PA conduits, pulmonary valve placement, or Fontan *Correspondence to: Frank F. Ing, MD., Texas Children’s Hospital, 6621 Fannin St., MC 19345-C, Houston, TX 77030, (832) 826-5979. E-mail:
[email protected] Received 18 May 2010; Revision accepted 3 June 2010 DOI 10.1002/ccd.22694 Published online 4 November 2010 in Wiley Online Library (wileyonlinelibrary.com)
PA Stents Following Surgical Manipulation
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Fig. 1. Diagram outlining outcomes of stents in patients whom underwent further cardiac surgery.
revisions. At the time of this subsequent surgery, the stents are often manipulated and many subsequently require future catheter based interventions. There is no current data on how various surgical manipulations may affect the integrity of the stents and ultimately, the need for future intervention on the branch pulmonary arteries. The objective of this study is to evaluate factors associated with future catheter reintervention on stented branch PA’s after surgical PA stent manipulation performed during procedures not primarily related to branch PA stenosis.
METHODS
The electronic cardiac database was searched from September 1989 to December 2006 for all cases coded with PA stent and subsequent cardiac surgery. The operative reports were reviewed and cases where the primary indication was not branch pulmonary stenosis (BPS) were included. Catheterization and operative reports were reviewed and data included were age and weight at stent placement, residual gradient, diagnosis, gender, type of stent, age at subsequent surgery as well as indication for and type of surgery. Operative reports were reviewed and surgical manipulation was recorded as removed, trimmed, or longitudinal transection with patch (Fig. 1). Those stents that were not manipulated were defined as untouched. All follow up catheterizations were analyzed for reintervention including stent or balloon dilation on the indexed branch PA.
Data Analysis Statistical analysis was performed using SPSS version 12.0.1 software (SPSS Inc, Chicago, IL). All data is presented as median (range). Mann-Whitney U analysis was used to compare continuous variables in the two major groups of patients who had surgical manipulation of the stents, and those patients who did not to determine if there were any significant baseline differences between these two groups. Chi-square analysis was similarly performed for categorical variables. Kaplan-Meier analysis was performed to evaluate time to reintervention for various stent management strategies. Factors associated with time-dependent outcomes were analyzed using Cox regression analysis. Factors significant by univariable analysis were entered into a multivariable model using Forward stepwise entry. A two-sided p-value of
