Inadvertent Ligation of the Main Pulmonary Artery During Intended Patent Ductus Arteriosus Ligation in an Extremely Preterm Infant

Abstract

Patent ductus arteriosus (PDA) is a common condition in premature infants, and its management has evolved over time. Although medical closure remains the first-line approach, transcatheter PDA closure has gained increasing popularity and, in well-resourced settings, is progressively replacing surgical ligation. Nevertheless, surgical ligation continues to be performed in many parts of the world for medically unresponsive, hemodynamically significant PDA.

While numerous complications of surgical PDA ligation have been described, we report a rare and exceedingly uncommon inadvertent ligation of the main pulmonary artery (MPA) as a complication of surgical PDA closure. This case describes a 24-week gestation infant with a birth weight of 660 g who developed clinical deterioration and a loud cardiac murmur shortly after surgical ligation. Post-ligation echocardiography demonstrated a high systolic gradient across the distal MPA, consistent with partial ligation of the vessel, along with a persistently patent PDA.

At repeat surgery, the PDA clip was found to be placed across the distal MPA, with the PDA remaining widely patent, confirming the echocardiographic findings. The clip was removed, the MPA was repaired, and the PDA was successfully closed. This case highlights a rare but potentially catastrophic complication of surgical PDA ligation. Awareness and early recognition of this rare complication may be lifesaving.