Use of Cutting-Balloon Angioplasty in a Hybrid Setting: A New Application of the Hybrid Approach

ABSTRACT: The hybrid approach to the therapy of congenital heart disease consists of the combination of surgical and interventional techniques in order to improve safety and to achieve better results. Here we report on a new application of this concept: the use of cutting-balloon angioplasty in a hybrid setting. After failure of conventional angioplasty by using high-pressure balloons, a 2-year-old girl with a diagnosis of tetralogy of Fallot with pulmonary atresia and hypoplasia of the pulmonary arteries underwent cutting-balloon angioplasty of a tight stenosis of the left pulmonary artery in the operating room. The procedure allowed the salvage of the left pulmonary artery and the result was stable during follow up. Advances in techniques and materials for interventional cardiac catheterization have significantly improved results and reduced the occurrence of complications. In recent years there has been major conceptual and practical achievement in this field obtained through the collaboration between cardiac surgeons and interventional cardiologists. This is known as the hybrid approach to the treatment of congenital heart defects. This approach entails the combination of surgical and interventional techniques in order to improve safety and achieve better results.1–4 We report here on a new application of this concept: the use of cutting-balloon angioplasty (CBA) in a hybrid setting. Case Report. A 2-year-old girl was diagnosed with tetralogy of Fallot with pulmonary atresia and hypoplasia of the pulmonary arteries. She underwent implantation of a 4 mm left aorto-pulmonary shunt when she was 2 weeks old. Due to increased cyanosis at the age of 12 months, she underwent surgical implantation of a 5 mm central aorto-pulmonary shunt associated with plasty of the right pulmonary artery by using pericardium. The previous shunt was closed. When the patient was 18 months old, she underwent cardiac catheterization due to significantly increased cyanosis (oxygen saturation: 70%). The hemodynamic study showed a patent shunt, a moderately hypoplastic right pulmonary artery and a hypoplastic left pulmonary artery (LPA) with a severe stenosis (Figure 1). By passing through the central systemic-to-pulmonary shunt, a 0.014-inch BMW guidewire (Abbott Vascular, Abbott Park, Illinois) was placed distally and attempts at angioplasty were performed by using 2 x 20 mm, 3 x 20 mm and 3.5 x 20 mm Maverick balloons (Boston Scientific Corp., Natick, Massachusetts) inflated up to 14 atm (Figure 1). No improvement of the stenosis was made. Due to the tortuous course of the shunt, a percutaneous attempt with a cutting balloon was considered impossible. In fact, even a 4 Fr multipurpose angiographic catheter did not pass through the central shunt. After discussion with the surgeon, we decided to use CBA in a hybrid setting during a surgical procedure of the right ventricular outflow opening with a patch. The patient’s parents gave their informed consent to the procedure. In the operating room, after the opening of the sternum, the surgeon created a small incision and placed a purse-string suture on the atretic pulmonary trunk. A 6 Fr short introducer (5.5 cm long) was placed in the pulmonary trunk. Angiography was performed in order to help position a 0.014-inch guidewire in the distal pulmonary branches of the LPA by using a 4 Fr multipurpose catheter and under fluoroscopic guidance. Cutting balloons (Boston Scientific) (3 x 15 mm and 4 x 15 mm) were sequentially used under fluoroscopy to treat the resistant LPA stenosis (Figure 2). Angiographic control showed a good result with improvement of the diameter of the stenosed area from 0.5 mm to 3 mm (Figure 2). The time required to complete the CBA procedures was 20 minutes. Surgical opening of the outflow tract with a patch was then performed. At the end of the procedure, the oxygen saturation increased to 85%. The postoperative course was uneventful and the patient was discharged home 10 days later. Echocardiographic controls showed good flow in both pulmonary arteries. Eight months after surgery, the patient underwent hemodynamic and angiographic studies due to increased oxygen desaturation. A stable result was found at the level of the LPA treated with the cutting balloon during the previous procedure. However, the patient showed a severe stenosis at the origin of the LPA and hypoplasia of the right pulmonary artery. At this point, 2 stents were implanted simultaneously in both pulmonary arteries (Figure 3). No complications occurred and the patient was discharged home 2 days later on aspirin 5 mg/kg/daily. Surgery to close the patient’s ventricular septal defect is planned for a later date. Discussion. CBA has been proved to be very useful in treating difficult and very resistant vessel stenosis, in particular in the pulmonary arteries. CBA was introduced at the beginning of the past decade by Barath.5 With this technique, when the angioplasty balloon is inflated, three or four microblades incise the intima and media of the artery. The technique was used successfully to treat coronary artery stenosis resistant to dilation with high-pressure balloons.6 The use of CBA in the field of congenital heart defects is more recent. In fact, since the first reports by Schneider,7 CBA was used to dilate resistant stenoses of major systemic-to-pulmonary collateral arteries8 to create an atrial septal defect9 to dilate the infundibulum and pulmonary valve in patients with unoperated tetralogy of Fallot,10 and to treat resistant pulmonary artery stenosis.11–14 Treating stenosis of small branches of the pulmonary arteries is one of the biggest challenges in patients with congenital heart disorders. The success rate of standard balloon angioplasty is 30–50%, and it rises to 80% if high-pressure balloons are used;15 however, some pulmonary artery stenoses are resistant to balloon angioplasty despite the use of pressures as high as 18–20 atm. The introduction of the cutting balloon has provided an effective alternative as a complementary technique to standard or high-pressure balloon angioplasty. The hybrid approach to treat congenital heart disease consists of the possibility to integrate surgical and transcatheter approaches in order to improve safety and outcomes. The hybrid concept has been used to treat various congenital heart defects, such as in patients with ventricular septal defects,1,2 to implant stents in pulmonary arteries2 and to perform hybrid stage I palliation using pulmonary artery bands and patent ductus arteriosus stenting.3,4 To our knowledge, CBA has never been used in a hybrid setting. In our case, transcatheter angioplasty by using standard and high-pressure balloons was attempted without success. The use of percutaneous CBA was considered impossible due to the very tortuous course of the central shunt. The possibility of surgical plasty of the pulmonary artery was excluded due to the poor results in these cases and the severe hypoplasia of the left pulmonary artery in our patient. CBA used in the hybrid setting did not modify the surgical procedure; bypass time did not change since this was performed before the patient was placed on cardiopulmonary bypass. CBA allowed successful dilation of the resistant stenotic lesion area and the result was stable during follow up. This approach was very useful in avoiding the potential loss of the left pulmonary artery. In conclusion, the use of CBA in a hybrid setting is feasible and very useful. Strong collaboration between pediatric cardiologists and cardiac surgeons is mandatory for a successful outcome.

1. Bacha EA, Cao QL, Galantowicz ME, et al. Multicenter experience with perventricular device closure of muscular ventricular septal defects. Pediatr Cardiol 2005;26:169–175.
2. Bacha EA, Hijazi ZM, Cao QL, et al. Hybrid pediatric cardiac surgery. Pediatr Cardiol 2005;26:315–­322.
3. Akintuerk H, Michel-Behnke I, Valeske K, Mueller M, Thul J, Bauer J, Hagel K, Kreuder J, Vogt P, Schranz D. Stenting of the arterial duct and banding of the pulmonary arteries. Basis for combined Norwood stage I and II repair in hypoplastic left heart. Circulation 2002;105: 1099–1103.
4. Bacha EA, Daves S, Hardin J, et al. Single ventricle palliation for high risk neonates: The emergence of an alternative hybrid stage I strategy. J Thorac Cardiovasc Surg 2006;131:163–171.
5. Barath P, Fishbein MC, Vari S, Forrester JS. Cutting balloon: A novel approach to percutaneous angioplasty. Am J Cardiol 1991;68:1249–1252.
6. Unterberg C, Buchwald AB, Barath P, et al. Cutting balloon coronary angioplasty — Initial clinical experience. Clin Cardiol 1993;16:660–664.
7. Schneider MBE, Zartner P, Magee AG. Images in cardiology: Cutting balloon for treatment of severe peripheral pulmonary stenosis in a child. Heart 1999;82:108.
8. Mertens L, Dens J, Gewillig M. Use of a cutting balloon catheter to dilate resistant stenoses in major aortic-to-pulmonary collateral arteries. M Cardiol Young 2001;11:574–577.
9. Schneider MBE, Zartner P, Magee AG. Trans-septal approach in children after patch occlusion of atrial septal defect: first experience with the cutting balloon. Catheter Cardiovasc Interv 1999;48: 378–381.
10. Carlson KM, Neish SR, Justino H, et al. Use of cutting balloon for palliative treatment in tetralogy of Fallot. Catheter Cardiovasc Interv 2005;64:507–512.
11. Rhodes JF, Lane GK, Mesia CI, et al. Cutting balloon angioplasty for children with small-vessel pulmonary stenoses. Catheter Cardiovasc Interv 2002;55:73–77.
12. Bergersen LJ, Perry SB, Lock JE. Effect of cutting balloon angioplasty on resistant pulmonary artery stenosis. Am J Cardiol 2003;91:185–189.
13. Sugiyama H, Veldtman GR, Norgard G, et al. Bladed balloon angioplasty for peripheral pulmonary artery stenosis. Catheter Cardiovasc Interv 2004;62:71–77.
14. Butera G, La Torre M, Chessa M, Carminati M. Expanding indications for the treatment of pulmonary artery stenosis in children by using cutting balloons. Catheter Cardiovasc Interv 2006;67:460–465.
15. Gentles TL, Lock JE, Perry SB. High pressure balloon angioplasty for branch pulmonary artery stenosis: early experience. J Am Coll Cardiol 1993;22:867–872.