经导管法栓塞未闭动脉导管

21例动脉导管未闭(PDA)患者采用经皮导管栓塞术。年龄9～28岁(平均14.69岁)。男性8例,女性13例。用Ivalon塞子栓塞PDA。其中1例手术,20例1次栓塞成功。本文提出PDA栓塞的适应证、并发症和操作经验,证明能够治愈有选择的患者。     

Double-umbrella device for transvenous closure of patent ductus arteriosus and atrial septal defect: first experience

A new device for transcatheter closure of heart defects was constructed and used to close a patent ductus arteriosus (PDA) in seven adult patients and an atrial septal defect (ASD) in six adult patients. The device consisted of two self-opening umbrellas and a piece of Ivalon. A Dacron patch was sewn on the "male" umbrella for the ASD closure. The device required a 9 Fr introducing venous sheath for PDA and a 14 Fr sheath for the ASD. The venoarterial (right femoral vein-PDA or ASD-left femoral artery) long wire track was arranged. The "male" umbrella and the Ivalon were inserted transvenously one after another, advanced over the long wire across the PDA or ASD and extruded into the aorta or left atrium, respectively. The "female" umbrella was advanced transvenously over the long wire into the pulmonary artery (for PDA) or into the right atrium (for ASD). The metal conus on the long wire was used to pull the "male" umbrella while a special stiff pusher was used to bring the "female" umbrella to the "male" umbrella along the long wire. By these means the umbrellas interlocked at the defect level and closed it. The long wire was then removed through the left femoral artery. Protrusion of the interlocked device through the PDA occurred in one patient and through the ASD in two patients. In all three patients the device was kept on the wire until surgery and an early postrelease device embolization was avoided. In all other patients the defects were successfully closed. The follow-up of 3-27 months was uneventful in all patients. These results indicate that the described procedure is effective and safe, and warrants further clinical trial.     

Real-time bidimensional-color Doppler evaluation of patent ductus arteriosus

In order to assess the presence and severity of left-to-right shunt at ductal level, eleven patients with proven ductus arteriosus (PDA), ages 1 day to 16 years, were examined by real-time two-dimensional Doppler echocardiography. Eighteen subjects with no signs of cardiovascular disease were selected as normal controls. Normal pulmonary flow pattern was clearly visualized in the healthy subjects examined. The jet stream through the ductus was well imaged in the main pulmonary artery in patients with PDA and disappeared in two infants after pharmacologic manipulation with indomethacin. The colour-coded shunt area was related to the left-to-right shunt calculated at cardiac catheterization. Moreover, the combined use of colour-flow Doppler and continuous-wave Doppler yielded a reliable noninvasive assessment of pulmonary artery pressure.     

Transcatheter closure of large patent ductus arteriosus (> or = 4 mm) with multiple Gianturco coils: immediate and mid-term results.

OBJECTIVE: To assess the immediate and mid-term results of transcatheter closure of patent ductus arteriosus (PDA) > or = 4 mm with multiple Gianturco coils. (Transcatheter closure of large PDAs using the Rashkind occluder or the buttoned device is associated with a 7-38% incidence of residual shunt.) METHODS: 19 patients (7 male, 12 female) underwent an attempt at anterograde transcatheter closure with multiple Gianturco coils of a large PDA at a median age of 3.8 yr (range 2 weeks-34 yr) and median weight of 14 kg (range 2.3-80 kg). RESULTS: The median PDA diameter at the narrowest segment was 4.3 mm (range 4-7 mm) and the mean (SD) Qp/Qs was 1.9 (0.8). Each patient had left atrial and left ventricular volume overload. A 4F catheter was used to deliver the coils in all patients. There was immediate and complete closure in 16/18; one patient had residual shunt that was closed at a second procedure and the other had spontaneous disappearance of the residual shunt at the six week visit. A short ductus (angiographic type B) in one patient could not be closed. The median number of coils placed at the first attempt to close the ductus was 4 (range 2-6 coils) and the median fluoroscopy time was 40 minutes (range 13-152 minutes). Mild left pulmonary artery stenosis occurred in the two smallest patients. Coil migration to the lung occurred in 3 patients with retrieval of coils in two patients. All procedures but one were done on an outpatient basis. At a median follow up of 1.6 yr (range 2 weeks-2.2 yr) all patients had complete closure with no new complications. CONCLUSIONS: Anterograde transcatheter closure with multiple Gianturco coils is an effective treatment for most patients with large PDA of diameters up to 7 mm. This technique can be performed in small infants on an outpatient basis without the need for general endotracheal anaesthesia.     

Endoluminal closure of ductus arteriosus. A cooperative study

Thirty-two patients from 3 Pediatric Cardiological Centres underwent attempted endoluminal transcatheter closure of a patent ductus arteriosus. The patients' age ranged from 8 months to 67 years, but there were only 2 adults (18 and 67 years) in this series. All patients had a murmur which was continuous in 28 cases and systolic in 4 cases. Nine patients had left ventricular hypertrophy on the electrocardiogram and radiological cardiomegaly. Closure of the patent ductus was attempted by Rashkind's technique using a double umbrella of 12 mm diameter for ductus less than 4 mm diameter (26 cases), and an umbrella of 17 mm diameter when the ductus was wider (6 cases). The immediate results judged by retrograde aortography showed total occlusion in 12 patients and incomplete closure in 17 others with persistence of a minimal left-to-right shunt. In 3 cases, embolisation of the umbrella into the left pulmonary artery (2 cases) or right pulmonary artery (1 case), required thoracotomy to extract the umbrella and at the same time section-suture of the ductus arteriosus. Color Doppler echocardiographic follow-up showed the disappearance of the residual shunt in seven children.     

Rare case of pulmonary arteriovenous fistula simulating residual defect after transcatheter closure of patent foramen ovale for recurrent paradoxical embolism.

We report on a patient suffering from recurrent cerebrovascular events despite previous transcatheter closure of persistent foramen ovale (PFO) with a Helex occluder. There was evidence of persistent left-to-right atrial shunt shown by transesophageal contrast echocardiography and the patient was admitted to our institution for interventional closure of the supposed residual defect. However, the PFO was completely closed by the device and left pulmonary artery injections showed a pulmonary arteriovenous fistula in the left lower lobe. This rare malformation may well explain the recurrent paradoxical embolism. Transcatheter fistula closure with coils was performed successfully. This case underlines that the existence of an isolated pulmonary arteriovenous fistula as a right-to-left shunt in patients with cryptogenic stroke should not be overlooked, even if a PFO is present and pulmonary arteriovenous fistula is not suggested by the initial physical findings or chest X-ray.     

应用国产封堵器治疗儿童大型动脉导管未闭的疗效研究

目的:评价应用国产封堵器经导管治疗儿童大型动脉导管未闭的安全性及有效性。方法:12岁以下大型动脉导管未闭患儿66例,应用国产封堵器经导管进行介入治疗,于术后1、3、6月及每年进行超声心动图等随访,观察有无残余分流及主动脉狭窄等,评估该方法的效果及安全有效性。结果:技术成功率97%。应用目前最大封堵器失败转外科手术1例,由于重度肺动脉高压,试封堵后肺动脉压力无明显改善而放弃治疗1例。手术即刻残余分流率为23%,随访观察1月后为3%,6月后所有64例患儿均无残余分流。结论:国产封堵器经导管治疗儿童大型动脉导管未闭安全可行。     

Percutaneous catheter closure of the ductus arteriosus in children and young adults

The double-disk occluding device suitable for use in infants and children with patent ductus arteriosus, developed by Rashkind and Mullins, has been available to this institution since December 1987 on an investigational basis. Results of 43 nonsurgical ductal closure attempts using this device in children and young adults between December 1987 and October 1988 are presented. Successful implantation was achieved in 42 patients (98%). In 25 patients a residual shunt was seen on angiography immediately after implantation. In 12 patients a residual ductal shunt was detected by Doppler 24 hours after implantation; 6-week follow-up studies showed a small residual shunt in only 3 patients. After a second occluder device was implanted in 2 of these patients, complete closure of the patient ductus arteriosus was achieved. In 1 patient, early in the series, the occluder device embolized to the left pulmonary artery, necessitating surgical removal at the time of ductus division. This event was the only serious complication; there were no deaths.     

Noninvasive Doppler echocardiographic evaluation of shunt flow dynamics of the ductus arteriosus

The pulsed Doppler technique was used to record the flow velocity patterns in the ductus arteriosus and the pulmonary artery in 26 patients with either isolated or complicated patent ductus arteriosus (PDA). In all patients, abnormal Doppler signals indicating left-to-right (L-R) or right-to-left shunt flow or both could be obtained at the site of the ductus arteriosus. These Doppler flow patterns determined within the ductus coincided with the direction of ductal flow seen on the contrast two-dimensional echocardiogram. No Doppler signals of shunt flow were demonstrated in any of 42 control subjects. The peak, mean, and diastolic velocities of the L-R shunt flow within the ductus were measured from the ductal flow velocity profiles. With the Doppler-derived measurements of the mean and diastolic velocities, patients with normal pulmonary arterial pressure and those with evidence of pulmonary hypertension could be correctly identified. In addition, the mean velocity of the diastolic antegrade flow portion obtained from the proximal left pulmonary artery, which was related to ductal L-R shunting, was measured in 16 patients with isolated PDA. This Doppler flow determinant showed a good linear correlation with the L-R shunt ratio determined by Fick's method (r = .88, p less than .01). Our technique permits the noninvasive evaluation of shunt flow dynamics in patients with PDA.     

经导管封堵动脉导管未闭介入治疗后残余分流

目的探讨经导管封堵动脉导管未闭(PDA)介入治疗后残余分流的可行性和临床疗效。方法自1997年3月至2001年8月16例PDA介入治疗后残余分流的患者,其中男4例,女12例,平均年龄5.9±2.4岁(2～9岁),平均体重17.7±5.4kg(9～28kg),应用不同介入方法经动脉或静脉途径封堵残余分流,首次介入治疗与再次介入治疗的时间间隔平均为1.5±1.1年(1天～3.5年)。结果残余分流直径平均为2.7±0.9mm(1.2～5.0mm)。15例成功完成残余分流封堵术,1例失败,技术成功率为94%(15/16)。单纯应用Cook可控弹簧圈9例(其中双弹簧圈2例),Rashkind双面伞2例,Sidris纽扣式补片1例,Amplatzer蘑菇伞2例,同时应用Cook可控弹簧圈和Sidris纽扣式补片1例。封堵术后即刻造影,3例仍有少量残余分流,完全闭合率为80%(12/15)。平均手术时间为75.0±22.8min(45～120min),平均X线透视时间为10.4±3.9min(5～20min)。股动脉并发症1例,其余无并发症出现。封堵术后24h复查超声心动图,所有残余分流均完全闭合(100%),在平均2年随访中未出现残余分流再通、封堵器移位和左右肺动脉狭窄。结论经导管封堵PDA介入治疗后残余分流安全、疗效确切、创伤小,可作为外科手术治疗PDA介入治疗后残余分流的一种替代方法。     

国产封堵器治疗并发重度肺动脉高压的动脉导管未闭

目的评价国产封堵器治疗并发重度肺动脉高压动脉导管未闭（PDA）的可行性及近期效果。方法采用经导管国产封堵器堵闭并发重度肺动脉高压PDA 9例,术后进行经胸超声心动图、X线及心电图复查随访。结果9例均封堵成功;2例术后残余分流,在30 d随访中完全消失;血流动力学及心功能在术后和随访期间均有显著改善。全部病例均无严重并发症。结论应用国产封堵器治疗并发重度肺动脉高压PDA,安全可行,近期效果好。     

Percutaneous balloon exploration and plug closure of arterial duct

Percutaneous plug closure of arterial duct (AD) was performed on 38 patients, with ages ranging from 6 to 54 years. The inside diameter of AD varied from 3.7 to 11.6 mm and the shunt size of AD was 8-77% of the pulmonary flow. A combined technique was used in the closure operation, which employs a balloon catheter to explore the size of AD as well as its distensibility and a catheter scale to examine the compatibility of the foam plug with the AD to be closed. Total occlusion was achieved in all the 38 cases, the success rate being 100%. Immediately after the procedure, blood oxygen analysis showed an interruption of the left-to-right shunt and the pulmonary artery pressure decreased from 4.71 +/- 0.80 to 3.34 +/- 0.53 kPa (P less than 0.001). Four to 7 days later, the cardiothoracic ratio reduced from 52.8 +/- 4.6 to 49.7 +/- 4.2% (P less than 0.001) and the cardiac index decreased from 6.00 +/- 1.31 to 4.46 +/- 0.80 L/min.m-2 (P less than 0.001). Random color Doppler flow imaging suggested no residual shunts. No major complications were observed in any of the cases and follow-up observations in 1 to 24 months showed no plug displacement or recanalization. In conclusion: the balloon exploration is able to make certain of the "occlusion diameter" of AD and the scale examination can surely sort out the plug most compatible with the AD to be closed, so that success of every step for the closure is ensured.     

Radiographic characteristics of Cook detachable and Gianturco coils as well as clinical results of transcatheter closure of the patent ductus arteriosus

PURPOSE: To describe the radiographic appearance of the Gianturco and the Cook detachable coils and present the clinical results in patients who underwent transcatheter closure of patent ductus arteriosus. MATERIALS AND METHODS: Between January 1994 and June 1997, eighty-two patients underwent closure of patent ductus arteriosus (PDA) using either Gianturco or Cook detachable coils. The chest x-ray and echocardiography of all patients were reviewed and the following parameters were evaluated: 1) the size of the heart (cardiothoracic ratio), 2) the position and the type of the coils in the postero-anterior and the lateral projection, 3) the number of coils used, 4) the existence of residual ductal flow, 5) Doppler velocity in the left pulmonary artery. RESULTS: Complete occlusion was achieved in 94%, and cardio-thoracic ratio regressed from 0.57 to 0.53 (p < 0.01), after a mean follow-up of 1.2 years. The identification of the different coils on the chest radiograph was successful in only 47% of cases, difficulties arising especially, when multiple coils were used. In 55 patients (67%) the coil position was judged to be optimal, in 27 patients (33%) suboptimal. The latter correlates with the presence of residual shunt. Multiple coils correlated more with a left pulmonary artery flow velocity exceeding 1.5 m/s. CONCLUSION: Coil-occlusion of patent ductus arteriosus is effective and leads to reduced cardio-thoracic ratio. Radiographic coil identification is possible but may be difficult if multiple coils are deployed. Suboptimal coil position led more often to residual PDA shunt. Multiple coils are more commonly associated with increased LPA velocities, but hemodynamic significant obstruction to flow is rare.     

应用国产封堵器介入治疗小儿动脉导管未闭的远期疗效

目的分析经导管国产封堵器治疗小儿动脉导管未闭（patent duetus arteriosus，PDA）远期随访资料，评价其远期疗效、安全性及影响疗效的因素。方法PDA患儿接受国产封堵器治疗302例，病例均随访至2006年12月，进行回顾性队列研究。结果PDA最窄处直径在2．0～16（4．1±1．3）mm，其中直径超过12mm10例（3．3％）。成功植入4／6～22／24mm大小的封堵器298例（98．6％）。完成了随访244例，随访率为81％，随访时间24～82个月。需要再次接受治疗4例（1．3％），其中接受介入治疗3例（0．9％），包括因残余分流而溶血2例；因封堵器移位接受外科治疗1例（0．3％）。1年和5年无事件发生率为98．0％。残余分流率在1d，1个月，6个月，12个月，24个月和36个月分别为10．4％，3．7％，2．1％，0．8％，0．5％和0。10例巨大PDA应用大型封堵器封堵成功。结论应用国产封堵器治疗小儿PDA远期疗效确切．安全性好。     

Hybrid endovascular stent-grafting technique for patent ductus arteriosus in an adult

A 51-year-old man was referred to our institution for patent ductus arteriosus (PDA) complicated by left ventricular dysfunction and pulmonary hypertension. Surgical closure of a PDA is usually carried out via a small posterior thoracotomy. However, thoracoscopic procedures are probably not appropriate in adults because of the frequency of calcification and the greater risk of rupture while ligating the ductus. To minimize surgical trauma, we used hybrid endovascular stent grafting combined with revascularization of the left subclavian artery, which enabled us to eliminate shunt flow to the pulmonary artery. At 11-month follow-up, the patient was asymptomatic and showed no complications.     

巨大动脉导管未闭的封堵治疗

目的 评价应用国产封堵器封堵治疗巨大动脉导管未闭（PDA）的疗效.方法 全组17例,男性8例,女性9例,年龄15～43（24.5±11.1）岁.主动脉造影示PDA最窄腰部内径为18～26（25.5±1.8）mm,需采用腰部直径20mm以上的封堵器方可操作成功.术后3d及3个月后复查超声心动图.结果 术前超声诊断,17例中6例合并重度肺动脉高压,17例患者中14例（其中5例合并重度肺动脉高压）封堵成功（操作和临床成功）,成功率为82％（14/17）.16例选用国产特制PDA封堵器,1例26 mm ASD因封堵器位置不能牢固地“站稳”而放弃封堵治疗;1例严重肺动脉高压且左向右分流为主存在少量右向左分流,经封堵试验为阻力性肺动脉高压不适宜治疗;1例术后第2天发生封堵器脱落入降主动脉,经捕获器成功取出体外,但死于误吸（迷走反射引起恶心呕吐）导致的严重肺部感染及感染性休克.封堵成功14例,封堵器直径为22～30（26.5±2.7）mm,术后即刻降主动脉造影检查示9例微量残余分流,均为封堵器中间存在云雾状分流,10 min后重复造影云雾状分流消失.术后3d及术后3个月超声心动图示患者所有左心内径增大均明显回缩,未发现残余分流和导管再通.结论 巨大PDA在可能的范围内尽量争取介入治疗,成功后较普通PDA血液动力学恢复更明显,可获得较好的收益/风险比.     

Safety and Feasibility of Transcatheter Closure of Large Patent Ductus Arteriosus Measuring ≥4 mm in Patients Weighing ≤6 kg

Objectives: The study aims to find safety of transcatheter closure of large patent ductus arteriosus (PDA) ≥4 mm in patients weighing ≤6 kg.
Background: Large PDA ≥4 mm in patients ≤6 kg challenge the interventionist due to need for large delivery sheath, kink of delivery sheath, and encroachment of aorta or pulmonary artery (PA) by the device. Many institutions refer them for surgery.
Methods: Preterm neonates and ducts with coarctation were excluded. All other patients were taken for catheter closure. Ducts with roomy ampulla were closed with multiple coils aided by bioptome, and others with Amplatzer duct occluders.
Results: Twenty-eight patients aged 2–18 months (median 5.5 months) and weighing 3.8–6 kg (median 4.7 kg) had large PDA (mean diameter 6.3 ± 2 mm) with hyperkinetic pulmonary hypertension. Four patients had bioptome-aided coil closure. Twenty-two other ducts were closed with devices. Two procedures failed due to sheath kink in one patient and device pulling through a duct in the other patient. Four infants needed blood transfusions. The mean procedural time was 42 ± 20 minutes. On a mean follow-up of 25.5 ± 14.8 months, there were no residual flows and no gradients across aorta or pulmonary artery.
Conclusions: Transcatheter closure of large ducts ≥4 mm might be considered safe and effective in infants weighing ≤6 kg also. Decision on coils versus devices depends on ductal morphology. On midterm follow-up with somatic growth, there was no occurrence of aortic or PA gradients.     

Safety and feasibility of transcatheter closure of large patent ductus arteriosus measuring >or=4 mm in patients weighing

Kothandam Sivakumar  Edwin Francis  Prasad Krishnan 《Journal of interventional cardiology》2008,21(2):196-203

经导管介入治疗婴幼儿大型动脉导管未闭临床疗效

目的探讨应用导管介入治疗直径≥5mm婴幼儿大型动脉导管未闭（patent ductus arteriosus．PDA）的临床疗效。方法回顾性分析60例大型PDA（直径≥5mm）患儿的临床资料,着重分析手术方法、临床疗效和随访结果。结果56例PDA采用Amplatzer或国产先健动脉导管封堵器．3例采用膜部室间隔缺损封堵器,1例采用肌部室间隔缺损封堵器。封堵成功率为98．3％（59／60）,术后1d超声心动图显示15％（9／60）微量至少量残余分流,术后3月超声心动图复查未见残余分流：3例采用室间隔缺损封堵器患儿术后12月超声心动图示左肺动脉血流速度增快。结论应用导管介入治疗直径≥5mm婴幼儿大型PDA是安全、有效的方法。     

Subclinical aortic perforation with the infant double-button patent ductus arteriosus occluder.

Modification of the double-button (Sideris) patent ductus arteriosus (PDA) occluder has resulted in a single-strut aortic component rather than the conventional cross-strut design. We report the use of this infant PDA occluder for transcatheter closure in three patients with PDA measuring 2 mm, 3.7 mm, and 4 mm. Subclinical aortic perforation with a small aortic aneurysm developed in two patients 1 year after occluder implantation. The third patient had developed a small aortic aneurysm without perforation at 3-month follow-up. All three patients had a residual shunt and underwent successful PDA surgical closure with aortic aneurysmal repair. Single-strut umbrella designs are not recommended for PDA transcatheter closure.