2025 Scientific Sessions

Title: Percutaneous VV ECMO Use for High-Risk Ductal Stenting

Introduction: Patent ductus arteriosus (PDA) stenting has emerged as a critical palliative intervention for neonates and infants with ductal dependent pulmonary blood flow (DDPBF). While surgical placement of a Blalock-Taussig-Thomas shunt has been traditionally performed to establish stable pulmonary blood flow, transcatheter stenting of the PDA has gained traction as a safe and effective alternative to surgical shunting. Despite its benefits, the procedure poses serious risk of ductal spasm, ductal injury, and hemodynamic collapse if pulmonary blood flow becomes compromised.

Clinical Case: We present the case of a term infant with pulmonary atresia-intact ventricular septum and non-right ventricular dependent coronary arteries who underwent staged ductal stenting using percutaneous venovenous extracorporeal membrane oxygenation (VV-ECMO) support. A first attempt at ductal stenting was complicated by ductal spasm and injury with pseudoaneurysm formation, resulting in obstructed pulmonary blood flow and a brief hypoxic-bradycardic arrest. The patient was stabilized and procedure aborted. Subsequently, supraphysiologic systemic pressures were required to maintain adequate pulmonary blood flow through the stenotic PDA, resulting in tenuous hemodynamics. The patient was deemed too high-risk for surgical shunt placement, leading to discussion regarding a second attempt at PDA stenting. Due to the heightened procedural risk and tenuous hemodynamics, we felt VV-ECMO may provide some intraprocedural stability during manipulations within the PDA and allow weaning of vasoactive support. Important pre-procedural considerations included ECMO team availability, surgical backup, ICU physician availability to manage ECMO throughout the case, appropriate anticoagulation, ECMO management post-intervention, and access site management. A 13-Fr Crescent RA Jugular Dual-Lumen Catheter (Medtronic, USA) was placed percutaneously from the right internal jugular vein (RIJ). To ensure the reinfusion port was facing the atrial septum rather than the tricuspid valve in the setting of pulmonary atresia, the cannula was rotated counterclockwise to create a “reverse L” rather than the typical “L” configuration recommended for the structurally normal heart. Using an ECMO flow of 0.37 liters per minute (LPM) with sweep flow of 0.25 LPM, and 40% FiO2 to the circuit, the patient was able to rapidly wean from vasoactive support. VV-ECMO allowed for excellent oxygenation and hemodynamic stability, enabling safe and successful PDA stenting despite significant ductal injury and extravasation of contrast during the second attempt. The patient was able to wean from VV-ECMO support immediately following the case and was decannulated without complication. Hemostasis was achieved using a “figure of eight” suture with a torque device. The patient was eventually discharged home with patency of the RIJ documented at the time of outpatient follow-up. To our knowledge, this is the first reported use of VV-ECMO for mechanical circulatory support (MCS) during a high-risk ductal stenting procedure.

Discussion: While PDA stenting may typically be performed without MCS, intraprocedural percutaneous VV-ECMO offers hemodynamic stability during complex ductal stenting procedures. This case demonstrates the novel application of percutaneous VV-ECMO as a viable intraprocedural support strategy in neonates undergoing high-risk PDA stenting.