A Review of Surgical Ligation of Patent Ductus Arteriosus in a Neonate

Introduction

As transcatheter technology improves, the need for surgical ligation of a patent ductus arteriosus (PDA) decreases. Until recently, no device was approved for infants <5 kg. The Amplatzer Duct Occluder II Additional Size (ADO II AS, Abbott Vascular, Santa Clara, California, USA) was approved by the US Food and Drug Administration for infants >700 grams and at least three days old (1). However, patients <700 grams and those with anatomy unamenable to this transcatheter technology will require a surgical approach. The purpose of this article is to serve as a refresher of the key technical and management points for surgical ligation of a PDA.

Surgical Technique

The procedure can be performed in the operating room or in the neonatal intensive care unit (NICU). At the authors’ institution, they prefer the NICU to obviate the risk of transport. Preoperative collaboration and planning with anesthesia is vital to ensure a safe operation. They utilize a checklist summarized (Figure 1 in video) to prepare for the case. The patient was placed in a right lateral decubitus position for a posterolateral left thoracotomy. The incision was placed directly under the scapula - which typically correlates to the third or fourt intercostal space. A 1.5 cm incision was made and a muscle-sparing thoracotomy was performed to allow for natural re-approximation of the latissimus dorsi and serratus anterior muscles. A malleable retractor was used to mobilize the left lung anteriorly. The pericardium was identified and dissected with electrocautery and blunt dissection just below the vagus nerve. It is vital to identify and avoid the vagus nerve. As the distal arch and PDA are dissected, it’s crucial to identify the descending thoracic aorta and left subclavian artery to avoid inadvertent ligation of these structures (Figure 2 in video).

Once these are identified, careful blunt dissection was used for near circumferential isolation of the PDA while identifying and avoiding the recurrent laryngeal nerve. It’s important to avoid manipulating the PDA directly, as this can be friable tissue. Once the PDA was circumferentially dissected, a test clamp was done and the lower extremity blood pressure was checked to ensure the descending thoracic aorta was not ligated. An appropriately sized vascular clip was found – it was placed around the PDA, while ensuring the vagus nerve was not involved, and the PDA was occluded with two vascular clips. These vascular clips are MRI compatible. The lung was then allowed to retract to its normal anatomic position. An 8-French pigtail catheter was then placed in a separate area in the anterior axillary line below the nipple. A figure-of-eight cicely suture was then used to re-approximate the ribs. The muscle and fascia were re-approximated using a Vicryl stitch and the skin was closed with a PDS suture.

Postoperative Management

Post ligation cardiac syndrome is a complication that up to 50% of very premature neonates will experience 6-12 hours after PDA closure. By closing off the low-pressure pulmonary circuit, the left ventricle is exposed to a simultaneous increase in afterload and decrease in preload, which is poorly tolerated and leads to hypotension. Management is based on providing volume to increase preload and inotropes to help the ventricle overcome the new increase in afterload. Milrinone and dobutamine are first-line agents for this scenario (2).

References

1. Regan W, Benbrik N, Sharma SR, Auriau J, Bouvaist H, Bautista-Rodriguez C, et al. Improved ventilation in premature babies after transcatheter versus surgical closure of patent ductus arteriosus [published online ahead of print, 2020 Mar 18]. Int J Cardiol. 2020 Jul 15;311:22-27.
2. El-Khuffash AF, Jain A, Weisz D, Mertens L, McNamara PJ. Assessment and treatment of post patent ductus arteriosus ligation syndrome. J Pediatr. 2014;165(1):46‐52.e1.

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