PDA Triple Ligation Technique
Triple ligation is a surgical technique for PDA closure that involves placing three separate ligatures around the patent ductus arteriosus, often supported on Teflon felt, to ensure complete occlusion and prevent recanalization. 1, 2
Technical Description
The triple ligation technique consists of:
- Placement of three separate suture ligatures around the ductus arteriosus to achieve secure closure 2
- Use of Teflon felt pledgets to support the ligatures and prevent tissue tearing, particularly important given the friability and calcification often present in adult ductal tissue 1, 2
- Surgical approach via thoracotomy (traditionally posterolateral, though transaxillary muscle-sparing approaches are now used) or sternotomy 1, 3
Clinical Context and Efficacy
This technique demonstrates excellent outcomes with minimal recanalization risk:
- Greater than 95% closure success rate with early mortality that is low 1
- Recanalization is rare when triple ligation is properly performed 1
- In one series of 16 adult patients, triple ligation on Teflon felt resulted in zero hospital mortality and only 1 case of recanalization during 1-7 years follow-up (mean 5 years) 2
When Triple Ligation is Indicated
Surgical ligation (including triple ligation) is recommended when: 1
- The PDA is too large for device closure 1
- Distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis) 1
- Calcified ductus is present, though consultation with interventional cardiologists should occur first as catheter intervention may be preferred 1
Important Surgical Considerations
Adult PDA anatomy poses specific challenges:
- Calcification and tissue friability in the area of the aortic isthmus and pulmonary artery make surgical manipulation more hazardous in adults than children 1
- Calcified ductus carries increased risk of rupture during surgical repair 1
- Ligation and division can be performed, or alternatively patch closure from inside the main pulmonary artery or aorta, depending on presence or absence of ductal calcification 1
Potential Complications
Surgical morbidity includes: 1
- Recurrent laryngeal nerve injury (reported in 5% in one series) 3
- Phrenic nerve injury 1
- Thoracic duct injury 1
- Pneumothorax (reported in 10% in one series) 3
Modern Context
Device closure has largely supplanted surgical approaches for most PDAs, particularly in adults where tissue friability increases surgical risk 1. However, triple ligation remains a reliable technique when percutaneous closure is not feasible due to size or anatomic considerations 1, 2.