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Technical misadventures during patent ductus arteriosus ligation: ligate with care
Brendan Campbell, *Melissa McCann, *Shefali Thaker, *Hank Leopold
Connecticut Children's Medical Center, Hartford, CT

BACKGROUND: Patent ductus arteriosus (PDA) ligation is the most common cardiovascular procedure performed on neonates in the United States. Currently there are no studies that characterize major technical mishaps that occur during this operation. The purpose of this study is to describe potentially catastrophic complications that occur during neonatal PDA ligations.
METHODS: We interviewed a convenience sample of ten pediatric subspecialists with firsthand knowledge of major intraoperative complications that occurred during neonatal PDA ligation cases from 1998 through 2013. Major complications were defined as hemorrhage greater than one blood volume and ligation of structure other than. Data collected for each case included year case was performed, type of complication, surgical approach, surgeon subspecialty training, hospital type, need for reoperation, and mortality.
Results: We identified sixteen cases with major intraoperative technical mishaps from eleven hospitals in eight states. Complications reported included 6 (38%) left pulmonary artery ligations, 4 (25%) major intraoperative hemorrhage, 3 (19%) bronchus ligations, 2 (13%) aorta ligations, and 1 (6%) hemiazygous vein ligation. Nine (60%) cases required reoperation and three patients died as a direct result of the surgical error. Subspecialty of the surgeon performing the initial procedure: pediatric general surgeons (n =9, 56%), adult cardiothoracic surgeons (n = 4, 25%), and pediatric cardiothoracic surgeons (n =3, 19%). Mean years since completion of fellowship training for the attending surgeon was 15 ± 10 years. Four (25%) cases involved a trainee.
Conclusion: Potentially catastrophic technical mishaps can and do happen to experienced surgeons who perform PDA ligations. Surgeons who perform this operation should have an actionable plan to deal with major intraoperative hemorrhage and always clearly identify juxtaductal anatomy before proceeding with ductal closure.


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