From the Guidelines
Surgical intervention is strongly recommended for all aneurysmal patent ductus arteriosus (PDAs) regardless of size due to their high risk of rupture, which can be fatal. Aneurysmal PDA is a rare but serious complication of an unclosed PDA, where the ductus arteriosus dilates abnormally over time due to continuous high-pressure blood flow between the aorta and pulmonary artery. The natural history involves progressive enlargement as the vessel wall weakens from hemodynamic stress, with potential complications including thrombus formation, embolization, compression of adjacent structures, and catastrophic rupture 1.
Surgical Implications
Surgical management typically involves open repair through a thoracotomy or sternotomy with resection of the aneurysm and closure of the communication between the great vessels. Endovascular approaches using covered stents may be considered in select cases but are often challenging due to the aneurysm's anatomy. The decision to perform surgical closure should be made in consultation with ACHD interventional cardiologists, especially for patients with calcified PDAs 1.
Risks
Major surgical risks include bleeding, infection, recurrent laryngeal nerve injury, chylothorax, and post-operative pulmonary complications. The proximity to vital structures like the recurrent laryngeal nerve, esophagus, and left main bronchus increases surgical complexity. Preoperative CT angiography or MRI is essential for surgical planning to delineate the aneurysm's relationship to surrounding structures 1. Without treatment, aneurysmal PDAs carry a high mortality risk, with rupture being particularly common during pregnancy or periods of increased hemodynamic stress.
Key Considerations
- The clinical and physiological manifestations of PDA are dependent on the size of the vessel and the relative systemic and pulmonary vascular resistances 1.
- Follow-up of patients with PDA as adults is important, with timing and testing varying among individuals 1.
- Surgical repair by a surgeon experienced in CHD surgery is recommended when the PDA is too large for device closure or when distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis) 1.
From the Research
Natural History of Aneurysmal PDA's
- Aneurysms of the ductus arteriosus (DAA) can occur spontaneously or following surgical treatment of a patent ductus arteriosus (PDA) 2
- The real incidence of DAA is presumably still underestimated, with 144 cases reported in the literature, including 106 spontaneous and 38 post-surgical cases 2
- Serious complications following spontaneous DAA include rupture, erosion, infection, and thromboembolism, with a complication rate of 31% in infants under 2 months, 66% in children between 2 months and 15 years, and 47% in adults 2
Surgical Implications
- Surgical closure of PDA is still required in selected adult patients, particularly those with wide, deformed PDAs unsuitable for percutaneous closure or those with associated surgical aortic or heart disease 3
- Surgical treatment of DAA is recommended in patients older than 2 months, with a low operative mortality in children over 2 months and adults 2
- In infants under 2 months, a DAA should be closely followed with echocardiography, as spontaneous regression has been reported in this age group 2
- Surgical closure of PDA can be performed using a transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest, with a Dacron patch used to close the duct 3
Risks
- The rate of complications following postoperative DAA is high, with 91% of unoperated cases resulting in death due to rupture or infection 2
- Operative mortality in patients with postoperative DAA is 26% 2
- Risks associated with surgical closure of PDA include perioperative complications, although all patients in one study survived the intervention and did not suffer perioperative complications 4
- Postoperative follow-up is essential to monitor for repermeabilization of the arterial duct or aneurysmal dilation of the adjacent aorta, although no cases were reported in one study after 36 months 4