Correspondence

A Simpler Technique for Umbilical-Cord Blockade of an Acardiac Twin

N Engl J Med 1994; 331:56-57July 7, 1994

Article

To the Editor:

The method reported by Quintero et al. (Feb. 17 issue)1 of umbilical-cord ligation of an acardiac twin by fetoscopy is clearly superior to hysterotomy2 and to ultrasound-guided procedures reported so far. The intraarterial placement of coils has been associated with recanalization of the umbilical cord, and the injection of fibrin or glue material has resulted in the death of both twins, most likely because of intravascular transfer of the material through vascular anastomoses in the monozygotic placentas. We have developed a simpler technique for in utero management of twins with reversed-arterial-perfusion sequence. This approach uses a much thinner needle, with no need for an additional optical canal, grasper, external knot-pushing, and the like.

A 29-year-old primigravida was referred at 21 weeks' gestation because of polyhydramnios. The presence of an acardiac twin with anencephaly was detected, with typical findings on Doppler sonography and a mild pericardial effusion as a sign of cardiac insufficiency. With a 0.9-mm spinal needle, such as is routinely used for amniocentesis, an injection into the umbilical cord was performed with multiple pieces (about 10 mm long) of standard surgical suture material soaked in 96 percent ethanol. This caused an immediate interruption of flow in the cord that could be recognized easily on real-time ultrasonography from the “white-out phenomenon” (Figure 1Figure 1Sonogram at 21 Weeks of Gestation, Showing an Acardiac Twin with Acephaly (Left) and a Normal Twin (Right) with Polyhydramnios.) in the fetal liver and in the segment of the umbilical cord between the injection site and the acardius acephalus. The polyhydramnios and the cardiac insufficiency disappeared in the remaining twin, and there were no complications such as uterine irritability or leakage of amniotic fluid. At term a healthy child of 2780 g with an Apgar score of 9 was delivered spontaneously, followed by the placenta and the acardius acephalus.

There is already considerable experience with this approach in neuroradiology and oncology, where it is applied to interrupt blood flow to arteriovenous malformations and to kidneys or liver with cancerous lesions. Surgical silk plus ethanol is known to produce massive endothelial damage even of larger vessels, with consequent vascular thrombosis3,4.

Our method is very inexpensive, takes little time, and does not require general anesthesia or the infusion of a solution to enhance visibility with the fetoscope as was used by Quintero et al.1 We think this alternative is not only cheaper but also easier to perform and presents less risk to the successful continuation of pregnancy.

Wolfgang Holzgreve, M.D.
Sevgi Tercanli, M.D.
Wolfgang Krings, M.D.
Gerhard Schuierer, M.D.
University of Munster, D-48129 Munster, Germany

4 References

1. 1

   Quintero RA, Reich H, Puder KS, et al. Umbilical-cord ligation of an acardiac twin by fetoscopy at 19 weeks of gestation. N Engl J Med 1994;330:469-471
   Full Text | Web of Science | Medline

2. 2

   Ginsberg NA, Applebaum M, Rabin SA, et al. Term birth after midtrimester hysterotomy and selective delivery of an acardiac twin. Am J Obstet Gynecol 1992;167:33-37
   Web of Science | Medline

3. 3

   Eskridge JM, Hartling RP. Preoperative embolization of brain AVMs using surgical silk and polyvinyl alcohol. AJNR Am J Neuroradiol 1989;10:882-882 abstract.
   Web of Science

4. 4

   Ellman BA, Parkhill BJ, Marcus PB, Curry TS, Peters PC. Renal ablation with absolute ethanol: mechanism of action. Invest Radiol 1984;19:416-423
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Quintero replies:

To the Editor: In the report by Holzgreve et al., the umbilical vessels of an acardiac twin were thrombosed by the injection of suture material soaked in 96 percent ethanol, and a successful pregnancy followed. The authors argue that this method is preferable to the endoscopic one my colleagues and I used in the case of an acardiac twin, because it does not require endoscopy, general anesthesia, or operating instruments. Although we agree that any effort to simplify the management of such cases is welcome, the two approaches are substantially different.

The method described by Holzgreve et al. is a variation of previously reported ultrasound-guided techniques1,2 in which a thrombogenic substance is injected into the umbilical cord. Recanalization of the thrombosed vessels and emboli to the normal twin, with death of both twins, has been associated with these intravascular techniques3,4. The concern my colleagues and I have about complications is not dispelled by the report of Holzgreve et al. On the contrary, the white-out image that reached the liver of the acardiac twin from the site of injection in the umbilical cord shows that the operator cannot control the extension of the thrombus or emboli. Moreover, accidental injection of the thrombogenic substance into a vessel exiting the acardiac twin can lead to the death of the normal twin. It can be very difficult to position the needle precisely in the correct vessel and to avoid accidentally dislodging the tip.

Our method relies on placing a knot around the umbilical cord. This stops blood flow in all the cord vessels of the acardiac twin and eliminates the possibility of emboli or vascular recanalization. We have subsequently performed other fetoscopic procedures with the patient under peridural anesthesia, and we are improving our instruments to minimize trauma to the uterus and membranes. Therefore, we believe that our approach, though perhaps more involved, represents a more reliable method of interrupting the circulation of the acardiac twin, without endangering the normal twin.

Ruben A. Quintero, M.D.
Hutzel Hospital, Detroit, MI 48201

4 References

1. 1

   Hamada H, Okane M, Koresawa M, Kubo T, Iwasaki H. Fetal therapy in utero by blockage of the umbilical blood flow of acardiac monster in twin pregnancy. Nippon Sanka Fujinka Gakkai Zasshi 1989;41:1803-1809
   Medline

2. 2

   Porreco RP, Barton SM, Haverkamp AD. Occlusion of umbilical artery in acardiac, acephalic twin. Lancet 1991;337:326-327
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   Grab D, Schneider V, Keckstein J, Terinde R. Twin, acardiac, outcome. Fetus 1992;2:11-13
   

4. 4

   Roberts RM, Shah DM, Jeanty P, Beattie JF. Twin, acardiac, ultrasound-guided embolization. Fetus 1991;1:5-10
   

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   T. Y. T. Tan, W. Sepulveda. (2003) Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound in Obstetrics and Gynecology 22:4, 409-419
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    S Erkaya. (2000) Acardiac twinning where the pump twin dies in utero due to thrombosis in the umbilical arteries. European Journal of Obstetrics & Gynecology and Reproductive Biology 90:1, 51-54
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    Keith R. Duncan, Mark L. Denbow, Nicholas M. Fisk. (1997) The aetiology and management of twin–twin transfusion syndrome. Prenatal Diagnosis 17:13, 1227-1236
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    Mark L. Denbow, Malcolm R. Battin, Phillipa M. Kyle, Roberto Fogliani, Pamela Johnson, Nicholas M. Fisk. (1997) Selective termination by intrahepatic vein alcohol injection of a monochorionic twin pregnancy discordant for fetal abnormality. BJOG: An International Journal of Obstetrics and Gynaecology 104:5, 626-627
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    Mary E. D'Alton, Lynn L. Simpson. (1995) Syndromes in twins. Seminars in Perinatology 19:5, 375-386
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