Traditionally, surgical shunts were used for cyanotic CHD, but interventional methods like PDA stenting are becoming a preferred alternative in suitable cases due to evolving technology and evidence [10, 11]. Studies have shown reduced complications (OR 0.4, P = 0.006) and improved pulmonary artery growth with PDA stenting [12]. Access site selection is crucial for the success of the procedure.

Access via the FA is most frequently utilized and often preferred due to its larger caliber and ease of ability to achieve safe homeostasis, especially in the neonate population [13]. Although widely adopted, the FA has risks of thrombosis and vessel spasm [5, 14], with some studies suggesting true thrombosis prevalence as high as 23.4% [15]. FA access often necessitates the use of long introducer sheaths for better control and simultaneous injections for positioning [16]. This is a significant consideration, as the use of long sheaths has been identified as an independent risk factor for arterial thrombosis; one study reported a complication rate of 38% compared to 15% with short, matching-size sheaths [16]. Recent developments, such as the wire twisting technique, as described by Kato et al., has allowed the use of the FA regardless of anatomical variations [14]. The umbilical approach shares this retrograde path to the PDA.

Despite the risks associated with FA use, it is still often favored since effective utilization of the carotid and axillary arteries requires both experienced interventionalists paired with careful vascular ultrasound guidance [17]. Even then, the possibility of pseudoaneurysm (a complication reported at 11% in a cohort study by Choudry et al. [17]) or aortic dissection/thrombosis (complications reported for axillary access at 5.6% for both in a cohort study by Haddad et al. [23]) may outweigh the advantage of a shorter catheter time offered by axillary/carotid access in tortuous PDA variants compared with femoral access [14]. However, CA/AA catheterization may be chosen in long, tortuous ductal anatomy (Type II and III [8]) due to favorable co-axial alignment, which facilitates stent delivery and reduces the risk of ductal spasm or malposition [2, 18]. Further to this, recent procedural series highlight the utility of axillary access within duct-dependent pulmonary circulation with tortuous ductal anatomy, as it provides a stable, coaxial approach that is not an end-artery, thereby preserving distal limb perfusion during the procedure [22].

Although the umbilical artery has no postnatal clinical significance, UAC still carries inherent risks. The most frequent complication is catheter rupture, which may cause hemorrhage, particularly if near the umbilical stump [19]. More severe but rarer complications, such as non-occlusive aortic thrombus, have been reported in studies like Levit et al., though this risk correlates with prolonged UAC dwell time and therefore may not apply to short-term interventional use [19].

While literature on umbilical artery access for interventions remains limited, potential procedural risks could theoretically include iliac artery injury or aortic dissection, given the catheter’s trajectory. However, none of these complications occurred in our small cohort. Our umbilical artery access cohort demonstrated excellent procedural safety, with no immediate complications (e.g., bleeding, thrombosis, or stent migration). These findings are mirrored by a recent series by Bazil et al. [20], where umbilical arterial access was used in the context of neonatal neurointervention. This recent series demonstrated a similar safety and efficacy profile of transumbilical access for the endovascular embolization of high-flow cerebrovascular malformations in 21 neonates, with a high technical success rate (20/21 intended cases) and absence of access-specific complications [20]. Although procedural nuances differ, (for example, Bazil et al. preserve their sheath for up to 10 days post-procedure [20]) the foundation that umbilical access is a viable alternative access method remains.

This contrasts with the CA access group (n = 20) in Alsawah et al.’s study, which reported a 15% complication rate (primarily pseudoaneurysm and procedural failure) [21]. The FA access cohort (n = 20) in that same study had significantly higher complications (45%, p = 0.038), including hematoma, thrombosis, and access failure, aligning with known risks in neonates [21]. The FA subgroup within Alsawah et al.’s [21] cohort exhibited comparable PDA typing to our umbilical cohort (60% type I/II); however, their CA population had notedly more complex PDAs (55% type III), limiting the conclusions we can draw from this subgroup.

Umbilical access required a longer median procedure time (126 min) compared to previous CA (71.5 min) and FA studies (75 min) [21, 22]. However, this difference is partly attributable to case complexity within our cohort, with three patients requiring an additional procedure alongside PDA stenting. Despite the longer duration, umbilical access offers important safety advantages, avoiding the neurologic complications associated with carotid or axillary routes (e.g., pseudoaneurysm, hemiparesis [17]) and the vascular complications reported with FA access in neonates [5, 14]. The umbilical approach may also benefit from emerging technologies – such as steerable microcatheters, which have demonstrated efficacy in complex vessel navigation [23]. While the additive effect of steerable microcatheters and umbilical access may produce superior operator experience and patient outcomes, our experience in this study suggests conventional catheterization technology is capable of excellent results in the context of umbilical access.

While umbilical artery access may offer advantages for PDA stenting based on complications, patient selection depends critically on ductal anatomy. This approach is most feasible when the PDA arises from the descending aorta or if it arises from the brachiocephalic trunk allowing straightforward antegrade cannulation. Figure 5 provides a 3D model of this anatomical criterion, showing a bilateral PDA case with one morphology suitable for umbilical access (solid arrow) and another that is not (dashed arrow). As such, pre-procedural imaging is essential to evaluate PDA morphology and determine candidacy for PDA stenting via the umbilical artery route.

It is important to note that umbilical artery access shares the same retrograde trajectory as femoral access and does not offer inherent geometric advantages in navigating PDA tortuosity. Rather, its primary value lies in providing an alternative access site during the brief neonatal window before umbilical closure, potentially preserving femoral vessels for future procedures.