Early clinical experience with partial amniotic carbon dioxide insufflation (PACI) during fetoscopic surgery in human fetuses

Aims: Partial amniotic carbondioxide insufflation (PACI) provides the most important strategy for improving visualization during difficult fetoscopic surgical procedures. Here we present our early clinical experience with this experimental approach in humans. Patients & Methods: Amniotic carbon dioxide insufflation was employed during a total of 29 fetoscopic procedures in human fetuses that were performed at our center between 19+2 to 33+2 weeks of gestation. Indications were twin-to-twin transfusion syndrome, diaphragmatic hernia, amnion band constriction, aortic valve stenosis, spina bifida iand laryngeal atresia. We analyzed maternal and fetal safety of this approach as well as insufflation length and pressures needed. Results: PACI offered a superior visualization during the 29 interventions that by far surpassed the one generally encountered within a fluid environment. As assessed by clinical and hemodynamic monitoring as well as ultrasound examinations, all mothers and fetuses tolerated PACI well. Acute or chronic maternal or fetal complications that could have been attributed to PACI were not observed. Insufflation times ranged between 15 and 480 minutes (mean 113, median 60 minutes). Maximum insufflation pressures ranged between 9 and 25mm Hg (mean 17, median 16). Conclusions: PACI lends itself as the most important tool for improving visualization of intraamniotic contents during fetoscopic surgical procedures and has been safe in all of our cases. As the experience with this experimental approach remains still very limited, continued assessment of its benefit, risk and safety is mandatory.