Surgical management of twin reversed arterial perfusion sequence

Objective The purpose of this study was to review our experience in the management of twin reversed arterial perfusion sequence to derive management recommendations. Study design All patients with twin reversed arterial perfusion sequence who were seen for consultation between 1993 and 2004 were studied. Criteria for umbilical cord occlusion included abdominal circumference of the twin reversed arterial perfusion fetus that was more than or equal to the pump twin, polyhydramnios (maximum vertical pocket ≥8 cm), abnormal Doppler studies or hydrops of the pump twin, or monoamniotic twins. Various surgical and access techniques for umbilical cord occlusion were used as they were developed. Results Seventy-four patients with twin reversed arterial perfusion sequence were studied. Sixty-five patients were considered surgical candidates, of which 51 patients underwent umbilical cord occlusion attempt. The overall perinatal survival for surgical candidates who had umbilical cord occlusion was 65% (33/51 patients) versus 42.9% (6/14 patients) for the surgical candidates who did not undergo umbilical cord occlusion (P = .1). However, perinatal outcomes in surgical patients were significantly better than expectantly treated surgical candidates if the dividing membrane was not disrupted purposely (22/28 patients; 78.5%; P = .02). Surgery within the sac of the twin reversed arterial perfusion fetus was feasible in 23.5% of patients and was associated with no incidence of premature rupture of membranes, with 83% perinatal survival, and with a significantly greater gestational age at delivery (36 weeks). There were no significant differences in perinatal outcome relative to the specific surgical technique that was used. Conclusion Surgical management of twin reversed arterial perfusion sequence is indicated in high-risk patients. The surgical approach and the surgical technique should be tailored to the specific clinical presentation, preferably by performing the surgery within the sac of the twin reversed arterial perfusion sequence fetus and avoiding disruption of the dividing membrane.