Severe haemolysis after transcatheter closure of a patent arterial duct with the new Amplatzer duct occluder

Severe mechanical haemolysis occurred in an 11-month-old boy after implantation of the new Amplatzer duct occluder. Temporary balloon occlusion of the aortic ampulla was performed 4 days after the initial procedure leading to prompt abolition of the haemolysis.     

Severe haemolysis after transcatheter duct occlusion: a non-surgical remedy.

Severe mechanical haemolysis occurred in a seven month old infant after the insertion of a 17 mm Rashkind double umbrella device. The placement of a second device 23 days after the initial procedure abolished haemolysis.     

Severe haemolysis after transcatheter duct occlusion: a non-surgical remedy.

Severe mechanical haemolysis occurred in a seven month old infant after the insertion of a 17 mm Rashkind double umbrella device. The placement of a second device 23 days after the initial procedure abolished haemolysis.     

Early implantation of multiple spring coils for severe haemolysis after incomplete transcatheter occlusion of persistent arterial duct.

An 18 month old girl with an angiographically measured ductus of 4.5 mm underwent transcatheter occlusion of the persistent arterial duct with a 17 mm Rashkind umbrella and an occluding spring coil. Severe intravascular haemolysis developed 20 hours later. Significant residual ductal leakage was noted and the residual duct measured 6 mm. Previous underestimation might have been related to ductal spasm as a catheter was placed across the duct before angiography. The haemolysis was abolished within 48 hours by a previously unreported approach of antegrade transcatheter closure of the residual duct by multiple spring coils.     

Problems encountered during introduction of Gianturco coils for transcatheter occlusion of the patent arterial duct

OBJECTIVE: To define the problems encountered during transcatheter occlusionof the patent arterial duct using Gianturco coils. METHODS: Between January 1994 and November 1995, 93 patients were admittedin whom it was intended to occlude the patent arterial ductusing Gianturco coils. Anterograde transcatheter coil occlusionwas performed via the femoral vein in 81 patients. In the remaining12 the procedure was done via the femoral artery. RESULTS: Coils were implanted successfully in 82/93 (88%) patients. In11 patients the procedure was a failure. In 19/93 patients (20%),inadvertent embolization of the coil occurred. The coils wereretrieved in all except one patient. In 17 of these patients,new coils were then reimplanted successfully. Doppler echocardiographyafter the procedure showed that in 9/82 (11%) patients the leftpulmonary artery Doppler peak velocity exceeded 1·5 m.s ^–1(mean 1·2 m. s.^–1) raising concern aboutleft pulmonary artery branch stenosis. The complete occlusionrate at discharge from hospital was 72/82 (88%). Follow-up rangesfrom 1 day to 14 months (mean 2/12 months) in the 82 patientsin whom successful deployment of coils was possible. In twopatients, the arterial duct became occluded at followup. Oneadditional patient had complete occlusion after reocclusionusing another coil. Thus, after short-term follow-up a totalof 75/82 patients (91·4%) have a completely occludedarterial duct after coil implantation. CONCLUSION: Transcatheter occlusion of the patent arterial duct using Gianturcocoils is an effective and safe technique. In the learning curvethere is a relatively high rate of inadvertent embolization,but the coils can be retrieved in the vast majority of patients.The complication rate is offset by the high early occlusionrate and the inexpensiveness of the procedure.     

Surgical ligation of a residually patent arterial duct following failed occlusion using transcatheter coils

Transcatheter techniques for occlusion of the persistently patent arterial duct using coils have become standard therapy at many centers for pediatric cardiology, and in selected patients have demonstrated comparable efficacy to surgical ligation. Surgical ligation may still be required in many cases, including premature infants or those born with low weight, those with ducts of large diameter, those with associated structural heart disease, and in circumstances of unsuccessful occlusion subsequent to attempted closure using coils. We report on the successful surgical ligation of an arterial duct of moderate size that exhibited residual patency despite two separate attempts at occlusion using coils.     

Coil occlusion of the small patent arterial duct without arterial access

BACKGROUND: Arterial access is traditionally considered mandatory during coil occlusion of the patent arterial duct. Arterial access necessitates heparinization and carries the risk of femoral artery occlusion in small children. METHODS AND RESULTS: Between July 1999 and May 2001, we attempted coil occlusion of patent arterial ducts in 104 patients without arterial access. The patients were aged from 3 months to 14 years. The median age was 2 years. They weighed 3-35 kg. The median weight was 9.8 kg. The duct diameter at pulmonary artery insertion was 1.8-3.5 mm. The patients were selected on basis of echocardiographic evaluation of duct diameter at pulmonary artery insertion and morphology of the ampulla. Doppler color flow imaging was used in the catheterization laboratory to confirm duct closure. Arterial access was required in 21 patients. The reasons included accidental puncture in 5 patients, failure to obtain venous access in 1 patient, aortic embolization in 3 patients, poor echo images in 2 patients, requirement for additional coils in 8 patients and, failure to cross the duct from pulmonary artery in 2 patients. The fluoroscopic time ranged from 2.2 to 20 min with a mean of 5.3+/-3.8 min. Immediate closure was achieved in 98 patients and this included 79 of the 83 patients in whom arterial access was avoided. Color Doppler 3-24 h later showed residual flow in 2 patients. Four patients had new-onset left pulmonary artery turbulence with peak gradients below 5 mm of mercury. Coil embolization occurred in 6 patients and all coils were retrieved. Three-month follow up information was available for 78 patients. Small residual ductal leaks were seen in 4 patients, 2 of whom had leaks at 24 h. Two patients had recanalized their ducts. CONCLUSION: It is feasible to occlude small patent arterial ducts with coils using venous access alone in carefully selected patients with excellent immediate and short-term results.     

Severe intravascular hemolysis after transcatheter coil occlusion of patent ductus arteriosus

Severe intravascular hemolysis is a rare complication of transcatheter closure of patent ductus arteriosus (PDA). It is thought to be secondary to red blood cell damage from a high-velocity jet from a residual shunt. However, only a small minority of patients with a residual shunt develop this complication. We report a case of intravascular hemolysis after partial coil occlusion of a PDA in which the Dacron strands were stripped off the coils during bioptome-assisted deployment. The exposure of the blood flow jet to bare metallic coils may have contributed to the occurrence of the severe hemolysis.     

Percutaneous transcatheter occlusion of the patent arterial duct using the pfm DuctOcclud Coil via a trans-aortic and trans-pulmonary approach

Occlusion using coils is now the treatment of choice for closure of the patent arterial duct. The DuctOcclud (pfm AG, Cologne, Germany) device is a relatively new retrievable coil for such trans-catheter closure. This study expands on previously reported experience with this device, summarizes the advantages of the device, and compares trans-pulmonary and trans-aortic delivery in 47 patients. There were 27 females. The mean, and median, ages were 4.6, and 2.85 years, respectively. The youngest patient was aged 9 months, weighing 7 kg. A trans-aortic delivery was used in 41 cases, and a trans-pulmonary approach in 6 cases. Of the 47 procedures, 45 (96%) were successful at the first attempt. The other two patients were treated successfully at the second attempt, giving a 100% rate of success. The technical characteristics of the coil allowed for its repeated maneuvering until an optimal position was obtained prior to release. Closure was confirmed by lack of ductal flow by echo-doppler on follow- up echocardiography. No short- or long-term complications of the procedure were noted in any of the patients. We conclude that the DuctOcclud device is an effective and safe method for closure of the small-to-moderately patent arterial duct. In a large proportion of patients, trans-aortic delivery is the preferred approach.     

Comparison of two transcatheter closure methods of persistently patent arterial duct

A randomized trial of arterial duct occlusion with a double umbrella (DU) or wire coil (WC) was undertaken for patients <18 years of age, weighing >10 kg with isolated ducts < or = 3 mm in diameter. Baseline, procedural, and outcome characteristics were compared in an intention-to-treat analysis according to randomization group. From 40 consecutively screened patients, 2 were not enrolled due to a ductal diameter of >3 mm on initial aortography, 38 patients were randomized to either the DU (n = 20) or WC (n = 18) groups. The groups did not differ significantly with respect to age, weight, gender, duct size, type, or branch pulmonary artery diameters. Crossover occurred only in the DU group, where 4 patients (20%) had a ductal diameter of < or = 1 mm and could not be entered for umbrella placement. All remaining DU group patients had ductal diameters of > or = 1.3 mm (p <0.0001). There were no embolizations or secondary implants in the DU group, but in the WC group there was 1 early and 1 late embolization, with 6 patients (33%) with > or = 2 coils. Mean times for the procedure (DU 68+/-19 minutes; WC 65+/-27 minutes; p = 0.70) and fluoroscopy (DU 14+/-4 minutes; WC 11+/-6 minutes; p = 0.22) did not differ significantly. Angiographic duct closure was documented in 4 of 13 patients (31%) of the DU group and 4 of 18 patients (22%) of the WC group (p = 0.69). Combined with an echocardiogram, closure in 11 of 17 patients with DU (65%) and 13 of 18 patients with WC (72%) (p = 0.64) was documented before hospital discharge. One WC group patient received thrombolytic therapy for a femoral artery thrombus. Follow-up at a median of 6.5 months (range 3.2 to 37) showed closure by Doppler echocardiography in 15 of 19 patients with DU (79%) versus 14 of 18 patients with WC (78%) (p = 1.0). Thus, with a tendency toward similar procedural characteristics and outcomes, the higher cost of the DU system compared with coil implants favors the use of coils for closure of the small arterial duct.     

Aortic obstruction caused by device occlusion of patent arterial duct

A 2 year old girl is reported in whom deployment of the Amplatzer ductal occluder caused significant aortic obstruction, requiring surgical removal of the device. This case emphasises the need for careful echocardiographic and angiographic assessment of the position of the Amplatzer ductal occluder before and after detaching the device from its delivery system, with particular emphasis on the position of the aortic retention ring. Careful assessment of ductal anatomy must guide case selection.     

Clinical evaluation of the new Amplatzer duct occluder II for patent arterial duct occlusion

Background: Several devices such as coils and Amplatzer duct occluder (ADO) are used for catheter closure of patent arterial ducts (PDA). These carry a high success rate but residual shunts, suboptimal device orientation, and technical problems are encountered. The Amplatzer duct occluder II (ADO II) is designed to address these limitations. Objectives: To evaluate the technical features of the new ADO II device for PDA closure and document the immediate/early closure rate, complications and device behavior during implantation. Methods: Prospective, two center study from February 2008 to January 2009. Twenty‐seven patients (18 females) received the ADO II. The median age was 22 months (range: 7 months–68 years) and the median weight was 11.7 kg (range: 6.9–108). The median PDA diameter was 2.6 mm (range: 1–4.4). The approach was arterial in 13 and venous in 14 patients. Follow‐up included echocardiography at 1 day and 1 month postimplantation. Results: All implantations were technically successful with immediate complete angiographic closure in 21 and trivial contrast flow in six patients. The median procedure time was 43 min (range: 15–82) and the fluoroscopy time was 6 min (range: 2.2–26.5). Echocardiography confirmed no residual shunts on the following day. There were no complications. Conclusion: The new ADO II is a versatile and very effective device for closure of PDAs of various shapes, lengths, and up to diameters of 5.5 mm. The disc articulations, high early closure rate, arterial or venous approach options, and small diameter delivery catheter are all beneficial features. © 2009 Wiley‐Liss, Inc.     

Successful transcatheter closure of patent arterial duct six years after balloon dilatation of coarctation of the aorta.

A boy underwent total transcatheter occlusion of a patent arterial duct six years after successful balloon angioplasty of a native coarctation of the aorta. After successful implantation of a 12 mm device in the patent arterial duct there was no gradient across the descending aorta and five hours later there was no residual leak across the occluded patent arterial duct as judged by color Doppler.     

Transcatheter management of residual shunts after initial transcatheter closure of a patent arterial duct

OBJECTIVES: To assess the efficacy and safety of transcatheter reocclusion of persistent leaks following previously attempted transcatheter occlusion of persistent arterial duct. DESIGN: Retrospective study. SETTING: Tertiary pediatric cardiology centre. PATIENTS: From February 1987 through October 1996, trans-catheter occlusion of a residual ductal shunt was attempted in 42 consecutive patients at a median age of 5.0 years (range 1.6 years to 16.2 years). INTERVENTIONS: Fourty patients had successful placement of a double umbrella occluder (n=27) or coils (n=13) across residual shunts. Complications included device embolization in two patients and hemolysis in one patient. OUTCOME MEASURES AND RESULTS: Mean z-score for left ventricular end-diastolic dimension (LVEDD) at initial echocardiography was +2.55 +/- 1.89 (P<0.0001 versus normal); z-score for left pulmonary artery (LPA) diameter was +2.00 +/- 1.52 (P<0.0001). Mean LPA to right pulmonary artery (RPA) diameter ratio was 1.05 +/- 0.18. At follow-up echocardiogram, a median of two years (range six months to 7.7 years) after the second procedure, a shunt was persistent in 3% of the patients. Mean LVEDD and LPA diameter z-value, and mean LPA to RPA diameter had dropped significantly to +0.42 +/- 1.31, +0.07 +/- 1.15 and 0.86 +/- 0.14 (P<0.001), respectively. LPA flow acceleration was present in 25% of patients. Three of nine patients, in whom lung perfusion scan was performed, had left lung perfusion below 40%. Small weight and age at catheterization were significant risk factors for LPA flow disturbance. CONCLUSIONS: Repeat transcatheter occlusion is safe and successful in eliminating residual shunt across the arterial duct. Attention should, however, be addressed to the potential for LPA stenosis and growth, and flow should be regularly assessed.     

Single catheter approach for occlusion of a patent arterial duct with a Rashkind double umbrella.

OBJECTIVES--To determine the benefits of using a single venous catheter and a single angiogram during catheter occlusion of a patient arterial duct with the Rashkind double umbrella compared with those of venous and arterial catheters and multiple angiograms. DESIGN--Retrospective review of case notes. PATIENTS--103 consecutive patients. The long sheath could not be advanced adequately in two patients. 101 patients had 104 implantations. Median (range) age was 35 (7-549) months and median (range) weight 13 (7-62) kg. Fifty four implantations were performed using the venous and arterial method and 50 using the venous only method. RESULTS--Median procedure times (70 v 90 min), number of angiograms (one v four), and angiographic dye volume used (2 v 7 ml/kg) were significantly reduced using the venous only method compared with those of the venous and arterial method. There was no significant difference in fluoroscopy time (venous only 9 v venous and arterial 10 min). CONCLUSIONS--Considerable improvements can be made in the technique of catheter closure of patent arterial ducts using the Rashkind double umbrella without compromising outcome using venous cannulation alone and a single angiogram, rather than venous and arterial cannulation and multiple angiograms. reduced risk to arteries from cannulation, The benefits are reduced radiation exposure, reduced risk to arteries from cannulation, shorter procedures, and lower equipment costs.     

Thoracoscopic closure of the patent arterial duct

Video assisted thoracoscopic surgery for closure of the persistently patent arterial duct is an effective answer to the modern effort of seeking repair of congenital cardiac malformations with minimally invasive techniques. Between June, 1994, and December, 2002, 150 consecutive patients with an echocardiographic diagnosis of isolated patency of the arterial duct were referred to our Institution for video assisted thoracoscopic closure. The median age at the time of operation was 45 months, with a range from 3 to 161 months, and mean weight was 18 kg, with a range from 4.2 to 73 kg. Video assisted closure was possible in 139 patients (93%). The mean operative time was 37 min, with a range from 14 to 89 min. In the remaining 11 patients (7%), seen early in our experience, we converted to a mini-thoracotomy to achieve closure. In no instance did we encounter major haemorrhage requiring blood transfusion, and there were no hospital deaths. The mean period of stay in hospital was less than 24 h in 61 patients, less than 48 h in 88 patients seen earlier in our experience, and 21 days in 1 patient because of a persistent chylothorax. Other complications included palsy of the left recurrent laryngeal nerve in 1 patient, with partial regression at 6 months follow-up. We conclude that closure of the arterial duct by video-assisted thoroscopy combines the advantages of safe and complete extraluminal occlusion with an excellent clinical and aesthetic result, minimal postoperative pain, and short stay in hospital at low cost.     

Aneurysm of the pulmonary trunk with patent arterial duct.

We present a 14-year-old female with a massive aneurysm of the pulmonary trunk occurring secondary to bacterial endocarditis of the patent arterial duct. Echo Doppler imaging, magnetic resonance and angiography confirmed the diagnosis. On intermediate follow-up after surgical correction, the echo studies and cardiac catheterization disclosed no residual lesions. The patient is now asymptomatic.