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Twin Reversed Arterial Perfusion
Anne M. Kennedy, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Abbreviations

              • Twin reversed arterial perfusion (TRAP)
            • Synonyms

              • Acardiac monster
              • Cardiac regression sequence
            • Definitions

              • Anomalous twin (TRAP twin) perfused by deoxygenated blood from pump twin
              • Blood enters fetus via umbilical artery (UA)
                • Reversed perfusion → selective development of torso/lower extremities
                • Lack of umbilical vein flow into heart → impaired/absent cardiac development

            IMAGING

            • General Features

              • Ultrasonographic Findings

                • MR Findings

                  • Imaging Recommendations

                    DIFFERENTIAL DIAGNOSIS

                      PATHOLOGY

                      • General Features

                        • Staging, Grading, & Classification

                          • Gross Pathologic & Surgical Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    DIAGNOSTIC CHECKLIST

                                    • Image Interpretation Pearls

                                      Selected References

                                      1. Mone F et al: Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med. ePub, 2015
                                      2. Stephenson CD et al: Microwave Ablation for Twin-Reversed Arterial Perfusion Sequence: A Novel Application of Technology. Fetal Diagn Ther. 38(1):35-40, 2015
                                      3. Takano M et al: Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 41(9):1326-9, 2015
                                      4. van Gemert MJ et al: Hypothesis acardiac twin pregnancies: Pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios. Birth Defects Res A Clin Mol Teratol. ePub, 2015
                                      5. van Gemert MJ et al: Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res A Clin Mol Teratol. 103(7):641-3, 2015
                                      6. Berg C et al: Twin reversed arterial perfusion (TRAP) sequence--does monoamniocity preclude early intervention? Ultrasound Obstet Gynecol. 44(2):241-2, 2014
                                      7. Chaveeva P et al: Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther. 35(4):267-79, 2014
                                      8. Downs EM et al: Sonographic assessment of a pregnancy complicated by a rare presentation of twin reversed arterial perfusion sequence. J Ultrasound Med. 33(10):1865-8, 2014
                                      9. Peeters SH et al: Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn. 34(6):586-91, 2014
                                      10. Prefumo F et al: Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 43(2):234-5, 2014
                                      11. Sommerfeldt JC et al: AIRP best cases in radiologic-pathologic correlation: twin reversed arterial perfusion sequence. Radiographics. 34(5):1385-90, 2014
                                      12. Oliver ER et al: Twin reversed arterial perfusion sequence: a new method of parabiotic twin mass estimation correlated with pump twin compromise. J Ultrasound Med. 32(12):2115-23, 2013
                                      13. Cavoretto P et al: Early diagnosis, follow-up, and prenatal treatment of a case of TRAP sequence occurring in a dichorionic triamniotic triplet pregnancy. J Clin Ultrasound. 37(6):350-3, 2009
                                      14. Kinsel-Ziter ML et al: Twin-reversed arterial perfusion sequence: pre- and postoperative cardiovascular findings in the 'pump' twin. Ultrasound Obstet Gynecol. 34(5):550-5, 2009
                                      15. Bornstein E et al: Detection of twin reversed arterial perfusion sequence at the time of first-trimester screening: the added value of 3-dimensional volume and color Doppler sonography. J Ultrasound Med. 27(7):1105-9, 2008
                                      16. Nakata M et al: Fetoscopic laser photocoagulation of placental communicating vessels for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 34(4 Pt 2):649-52, 2008
                                      17. Steffensen TS et al: Placental pathology in trap sequence: clinical and pathogenetic implications. Fetal Pediatr Pathol. 27(1):13-29, 2008
                                      18. Lee H et al: Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence. Am J Obstet Gynecol. 196(5):459, 2007
                                      19. Livingston JC et al: Intrafetal radiofrequency ablation for twin reversed arterial perfusion (TRAP): a single-center experience. Am J Obstet Gynecol. 197(4):399, 2007
                                      20. Morel O et al: Radiofrequency ablation for twin-reversed arterial perfusion sequence: the unknown cord occlusion delay calls for long term neonatal follow-up of the surviving twins. Am J Obstet Gynecol. 197(5):557-8; author reply 558, 2007
                                      21. Hecher K et al: Twin reversed arterial perfusion: fetoscopic laser coagulation of placental anastomoses or the umbilical cord. Ultrasound Obstet Gynecol. 28(5):688-91, 2006
                                      22. Quintero RA et al: Surgical management of twin reversed arterial perfusion sequence. Am J Obstet Gynecol. 194(4):982-91, 2006
                                      23. Wong AE et al: Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn. 25(9):796-806, 2005
                                      24. Hirose M et al: Successful intrauterine treatment with radiofrequency ablation in a case of acardiac twin pregnancy complicated with a hydropic pump twin. Ultrasound Obstet Gynecol. 23(5):509-12, 2004
                                      25. Kamitomo M et al: First-trimester findings associated with twin reversed arterial perfusion sequence. Fetal Diagn Ther. 19(2):187-90, 2004
                                      26. MacKenzie AP et al: Three-dimensional ultrasound to differentiate epigastric heteropagus conjoined twins from a TRAP sequence. Am J Obstet Gynecol. 191(5):1736-9, 2004
                                      27. Weisz B et al: Tailored management of twin reversed arterial perfusion (TRAP) sequence. Ultrasound Obstet Gynecol. 23(5):451-5, 2004
                                      28. Gimenez-Scherer JA et al: Malformations in acardiac twins are consistent with reversed blood flow: liver as a clue to their pathogenesis. Pediatr Dev Pathol. 6(6):520-30, 2003
                                      29. Tan TY et al: Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol. 22(4):409-19, 2003
                                      30. Dashe JS et al: Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence. Am J Obstet Gynecol. 185(1):135-9, 2001
                                      Related Anatomy
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                                      Related Differential Diagnoses
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                                      References
                                      Tables

                                      Tables

                                      KEY FACTS

                                      • Terminology

                                        • Imaging

                                          • Top Differential Diagnoses

                                            • Clinical Issues

                                              • Diagnostic Checklist

                                                TERMINOLOGY

                                                • Abbreviations

                                                  • Twin reversed arterial perfusion (TRAP)
                                                • Synonyms

                                                  • Acardiac monster
                                                  • Cardiac regression sequence
                                                • Definitions

                                                  • Anomalous twin (TRAP twin) perfused by deoxygenated blood from pump twin
                                                  • Blood enters fetus via umbilical artery (UA)
                                                    • Reversed perfusion → selective development of torso/lower extremities
                                                    • Lack of umbilical vein flow into heart → impaired/absent cardiac development

                                                IMAGING

                                                • General Features

                                                  • Ultrasonographic Findings

                                                    • MR Findings

                                                      • Imaging Recommendations

                                                        DIFFERENTIAL DIAGNOSIS

                                                          PATHOLOGY

                                                          • General Features

                                                            • Staging, Grading, & Classification

                                                              • Gross Pathologic & Surgical Features

                                                                CLINICAL ISSUES

                                                                • Presentation

                                                                  • Demographics

                                                                    • Natural History & Prognosis

                                                                      • Treatment

                                                                        DIAGNOSTIC CHECKLIST

                                                                        • Image Interpretation Pearls

                                                                          Selected References

                                                                          1. Mone F et al: Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med. ePub, 2015
                                                                          2. Stephenson CD et al: Microwave Ablation for Twin-Reversed Arterial Perfusion Sequence: A Novel Application of Technology. Fetal Diagn Ther. 38(1):35-40, 2015
                                                                          3. Takano M et al: Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 41(9):1326-9, 2015
                                                                          4. van Gemert MJ et al: Hypothesis acardiac twin pregnancies: Pathophysiology-based hypotheses suggest risk prediction by pump/acardiac umbilical venous diameter ratios. Birth Defects Res A Clin Mol Teratol. ePub, 2015
                                                                          5. van Gemert MJ et al: Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res A Clin Mol Teratol. 103(7):641-3, 2015
                                                                          6. Berg C et al: Twin reversed arterial perfusion (TRAP) sequence--does monoamniocity preclude early intervention? Ultrasound Obstet Gynecol. 44(2):241-2, 2014
                                                                          7. Chaveeva P et al: Optimal method and timing of intrauterine intervention in twin reversed arterial perfusion sequence: case study and meta-analysis. Fetal Diagn Ther. 35(4):267-79, 2014
                                                                          8. Downs EM et al: Sonographic assessment of a pregnancy complicated by a rare presentation of twin reversed arterial perfusion sequence. J Ultrasound Med. 33(10):1865-8, 2014
                                                                          9. Peeters SH et al: Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn. 34(6):586-91, 2014
                                                                          10. Prefumo F et al: Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol. 43(2):234-5, 2014
                                                                          11. Sommerfeldt JC et al: AIRP best cases in radiologic-pathologic correlation: twin reversed arterial perfusion sequence. Radiographics. 34(5):1385-90, 2014
                                                                          12. Oliver ER et al: Twin reversed arterial perfusion sequence: a new method of parabiotic twin mass estimation correlated with pump twin compromise. J Ultrasound Med. 32(12):2115-23, 2013
                                                                          13. Cavoretto P et al: Early diagnosis, follow-up, and prenatal treatment of a case of TRAP sequence occurring in a dichorionic triamniotic triplet pregnancy. J Clin Ultrasound. 37(6):350-3, 2009
                                                                          14. Kinsel-Ziter ML et al: Twin-reversed arterial perfusion sequence: pre- and postoperative cardiovascular findings in the 'pump' twin. Ultrasound Obstet Gynecol. 34(5):550-5, 2009
                                                                          15. Bornstein E et al: Detection of twin reversed arterial perfusion sequence at the time of first-trimester screening: the added value of 3-dimensional volume and color Doppler sonography. J Ultrasound Med. 27(7):1105-9, 2008
                                                                          16. Nakata M et al: Fetoscopic laser photocoagulation of placental communicating vessels for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res. 34(4 Pt 2):649-52, 2008
                                                                          17. Steffensen TS et al: Placental pathology in trap sequence: clinical and pathogenetic implications. Fetal Pediatr Pathol. 27(1):13-29, 2008
                                                                          18. Lee H et al: Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence. Am J Obstet Gynecol. 196(5):459, 2007
                                                                          19. Livingston JC et al: Intrafetal radiofrequency ablation for twin reversed arterial perfusion (TRAP): a single-center experience. Am J Obstet Gynecol. 197(4):399, 2007
                                                                          20. Morel O et al: Radiofrequency ablation for twin-reversed arterial perfusion sequence: the unknown cord occlusion delay calls for long term neonatal follow-up of the surviving twins. Am J Obstet Gynecol. 197(5):557-8; author reply 558, 2007
                                                                          21. Hecher K et al: Twin reversed arterial perfusion: fetoscopic laser coagulation of placental anastomoses or the umbilical cord. Ultrasound Obstet Gynecol. 28(5):688-91, 2006
                                                                          22. Quintero RA et al: Surgical management of twin reversed arterial perfusion sequence. Am J Obstet Gynecol. 194(4):982-91, 2006
                                                                          23. Wong AE et al: Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn. 25(9):796-806, 2005
                                                                          24. Hirose M et al: Successful intrauterine treatment with radiofrequency ablation in a case of acardiac twin pregnancy complicated with a hydropic pump twin. Ultrasound Obstet Gynecol. 23(5):509-12, 2004
                                                                          25. Kamitomo M et al: First-trimester findings associated with twin reversed arterial perfusion sequence. Fetal Diagn Ther. 19(2):187-90, 2004
                                                                          26. MacKenzie AP et al: Three-dimensional ultrasound to differentiate epigastric heteropagus conjoined twins from a TRAP sequence. Am J Obstet Gynecol. 191(5):1736-9, 2004
                                                                          27. Weisz B et al: Tailored management of twin reversed arterial perfusion (TRAP) sequence. Ultrasound Obstet Gynecol. 23(5):451-5, 2004
                                                                          28. Gimenez-Scherer JA et al: Malformations in acardiac twins are consistent with reversed blood flow: liver as a clue to their pathogenesis. Pediatr Dev Pathol. 6(6):520-30, 2003
                                                                          29. Tan TY et al: Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol. 22(4):409-19, 2003
                                                                          30. Dashe JS et al: Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence. Am J Obstet Gynecol. 185(1):135-9, 2001