Modified sequential laser photocoagulation of placental communicating vessels for twin–twin transfusion syndrome to prevent fetal demise of the donor twin

Abstract

Twin-twin transfusion syndrome (TTTS) complicated with absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) of the donor has a high perinatal mortality rate. To improve the prenatal outcome, we introduced and modified the technique of sequential selective laser photocoagulation of communicating vessels (SQLPCV), and assessed the clinical efficacy. The modified SQLPCV was designed with the following order of coagulation: (i) artery-to-artery (AA) anastomoses; (ii) venous-to-venous anastomoses; (iii) artery-to-venous anastomoses from donor to recipient; and (iv) artery-to-venous anastomoses from recipient to donor. TTTS patients with UA-AREDF of donors were recruited, and the perinatal outcome and its association with the types of anastomoses were compared in patients who underwent the standard selective laser method (SLPCV). Twenty-three patients underwent modified SQLPCV and 29 underwent SLPCV. Total intrauterine fetal death (IUFD) was significantly lower in modified SQLPCV than in SLPCV (9% vs 38%; P < 0.001). Donor IUFD was significantly lower in modified SQLPCV than in SLPCV (13% vs 52%; P = 0.007); however, no significant effect was noted in the recipient IUFD cases. When AA anastomoses were present, donor IUFD was significantly lower in modified SQLPCV than it was in SLPCV (18% vs 71%; P = 0.018); however, the difference was not significant when AA anastomoses were not present (8% vs 25%; P = 0.59). Logistic regression analysis revealed that modified SQLPCV served as the protective factor against the donor's IUFD (odds ratio = 0.015; 95% confidence interval [0.0001-0.775]; P = 0.037). The modified SQLPCV was useful for the prevention of the donor's IUFD in cases of TTTS with UA-AREDF.