Patent ductus arteriosus is a common cardiovascular problem in preterm infants, particularly those born very preterm. Persistent left-to-right shunting may cause pulmonary overcirculation, left-sided volume overload, and systemic hypoperfusion, yet simply promoting anatomical ductal closure has not been shown to improve major clinical outcomes. Management has increasingly shifted from routine closure toward selective intervention guided by hemodynamic effects and clinical risk. This review summarizes the applicability of different management strategies, the boundaries of current evidence, and a risk-stratified management approach, providing reference for clinical decision-making and future research.