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Experience with Polymer Locking Clips for Thoracoscopic Patent Ductus Arteriosus Closure
Alexey Arkhipov, Alexander Omelchenko, Yuriy Gorbatykh, Ilya Soynov, Alexander Bogachev-Prokophiev, Alexander Karaskov.
Academician Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.

OBJECTIVE: Various techniques have been suggested to improve safety during surgical closure of patent ductus arteriosus (PDA). In large PDA, which require multiple coils or Amplatzer device for closure, percutaneus techniques can lead to left pulmonary artery stenosis or aortic coarctation, embolization of the coils into the pulmonary circulation, vascular problems with a relatively large delivery sheath. Video-assisted thoracoscopic surgery (VATS) can be considered as a treatment of choice, but the clip selection can be a challenge.
METHODS: From 2011 to 2014, 50 patients with PDA underwent video-assisted thoracoscopic surgery. Our surgical approach implies four ports placement: two 3.5 mm for working instruments, one 6 mm for 5 mm 30 degree endoscope and 11 mm for clip applier. The pericardium should be dissected on the pulmonary side to protect the recurrent laryngeal nerve from a traumatic injury.
RESULTS: Mean age was 3,5 ± 3,0 years (range, 2 months - 13 years) and mean body weight was 15,0 ± 9,1 kg (range, 5 - 48 kg). Mean operating time was 24,5 ± 12,3 minutes. We started with Weck® Hemoclip® (Teleflex, Inc.) metal clips (29 patients). In this series 4 patients (13,8%) had a residual shunts, 2 of them underwent coil embolization. Because of high incidence of residual patency associated with the metal clips, Weck® Hem-o-lok® (Teleflex, Inc.) polymer locking ligation system had been chosen for the subsequent implementation in 21 patients. In none of them residual shunt had been revealed during postoperative period and follow-up. All patients had been discharged from the ICU in 15,6 ± 14 hours with mean ventilation time for 1,8 ± 0,6 hours after surgery. There was no mortality, bleeding or chylothorax in this series. There was one case of recurrent laryngeal nerve dysfunction, one case of pneumothorax and one case of postoperative pneumonia.
CONCLUSIONS: The technique of PDA closure by VATS is simple and safe alternative to open surgery in patients with PDA > 3 mm. Implementation of polymer locking clips reduces the risk of residual shunts to a minimum. It can be performed in all age group with minimal operating time and excellent cosmetic result.

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