Challenges and strategies of transcatheter closure for small-sized patent ductus arteriosus: a single-center real-world study

Transcatheter closure of small-sized patent ductus arteriosus (PDA) is technically demanding, and optimal strategies for guidewire rail establishment, morphology-guided device selection, and accurate imaging sizing remain poorly defined in the literature. To summarize the treatment strategies and analyze the intraoperative and perioperative challenges and countermeasures for transcatheter closure of small-sized PDA in children, based on single-center real-world data. A retrospective analysis was conducted on 41 children with small-sized PDA (narrowest diameter ≤ 2.5 mm on angiography) who were consecutively admitted to the Department of Pediatric Cardiology, Hainan Women and Children’s Medical Center, from January 2018 to December 2025. All patients underwent a stepwise strategy of “preferential antegrade venous approach, followed by femoral arteriovenous puncture to establish a rail technique” in case of failure, with individualized occlusion strategies formulated according to the Krichenko classification. Among the 41 patients, 16 were male (39%) and 25 female (61%), with ages ranging from 1 to 15 years (4.95 ± 3.29 years). Successful device implantation was achieved in 40 patients, yielding a procedural success rate of 98%. Angiographic morphological classification revealed: funnel-shaped in 16 cases (39%), tubular in 22 cases (54%) -- including 9 cases with length ≤ 7 mm and 13 cases with length > 7 mm -- window-shaped in 1 case (2%), aneurysm-shaped in 1 case (2%), and complex type in 1 case (2%). Device selection strategy was: mushroom-shaped occluders for funnel-shaped, tubular (length ≤ 7 mm), window-shaped, and aneurysm-shaped PDAs (27 cases, 67%); double-disc occluders for tubular PDAs with length > 7 mm (13 cases, 33%). One complex-type PDA failed occlusion. Immediate complete closure rate was 100% with no residual shunt. At 1-year follow-up, pulmonary artery systolic pressure (PASP) decreased from 31.63 ± 2.75 mmHg to 21.43 ± 1.22 mmHg (P < 0.01), and left ventricular end-diastolic diameter (LVEDD) and left atrial diameter (LAD) continued to improve (P < 0.01), indicating significant left ventricular reverse remodeling. No major adverse events such as device migration, thromboembolism, or vascular complications occurred during the perioperative period. In this selected single-center cohort, the arteriovenous rail technique combined with angiography-guided individualized device selection may help address the anatomical challenges of interventional closure for small-sized PDA, with high procedural success and favorable safety in the present cohort, providing some implications for optimizing congenital heart disease interventional practice.