CASE REPORT
Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach Endale Tefera1, Ramon Bermudez-Cañete2,3 1 2
Department of Pediatrics and Child Health, Cardiology Unit, School of Medicine, Addis Ababa University and Cardiac Center, Addis Ababa, Ethiopia, Ramon y Cajal University Hospital, Pediatric Cardiology Unit, Madrid, Spain, 3Volunteer Cardiologist, Cardiac Center, Addis Ababa, Ethiopia
ABSTRACT Percutaneous closure of the patent arterial duct in patients with interrupted inferior caval vein poses a technical challenge. A 12-year-old girl with a patent ductus arteriosus (PDA) and interrupted inferior caval vein is described in this report. The diagnosis of interrupted inferior caval vein and azygos continuation was made in the catheterization laboratory. A catheter was advanced and snared in the descending aorta. An exchange wire was advanced through the catheter and snared in the descending aorta. Then, an Amplatzer TorqVue 2 delivery sheath was advanced over the wire from the venous side and again snared in the descending aorta. An Amplatzer duct occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare. The device was opened. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted. The device was then released and it attained a stable position. An aortic angiogram was performed which showed complete occlusion. Keywords: Azygos continuation, device closure, interrupted IVC, patent ductus arteriosus
INTRODUCTION
CASE REPORT
Interruption of the inferior caval vein is a rare anomaly with an estimated incidence of 1 in 5,000 cases.[1] When interruption occurs, there could be azygos continuation or other patterns like blood flow being directed to a plexus of hepatic veins, or anomalous drainage of the inferior caval vein into the portal vein may occur.[2,3] Interruption of the inferior vena cava could make percutaneous closure of an arterial duct a challenging procedure. Various options, including right internal jugular vein approach, retrograde transarterial approach, and the conventional right femoral vein approach have been reported to be successful.[2-4] We report a case of large patent arterial duct with interruption of the inferior caval vein and azygos continuation; the patient underwent successful closure of the ductus through the conventional right femoral vein approach.
A 12-year-old girl who presented with dyspnea on moderate exertion and palpitation since three years was admitted for percutaneous closure of a patent arterial duct. Her infancy and childhood period were unremarkable and without cardiac symptoms. Her weight was 39 kg and height was 149 cm. Her blood pressure was 120/60 mmHg. Peripheral pulses were bounding. Precordial examination revealed active precordium with the point of maximum intensity shifted downward and laterally. There was thrill and continuous murmur over the left second intercostal space. Chest X-ray showed marked cardiomegaly. Electrocardiogram (ECG) showed sinus rhythm with a rate of 80 bpm and left ventricular hypertrophy. Echo showed dilated left atrium, left ventricle, and pulmonary artery, and a patent ductus arteriosus (PDA) of about 6 mm with a continuous leftto-right shunt.
Access this article online Quick Response Code:
Website: www.annalspc.com DOI: 10.4103/0974-2069.126560
Under general anesthesia, arterial access was established through the right femoral artery with a 4F introducer and aortic pressure was measured (86/53 mmHg, mean: 69 mmHg). Then, aortic angiogram was done [Figure 1]. A duct measuring 5 mm was seen. On right heart catheterization, it was found that the inferior caval vein was interrupted and that there was azygos continuation.
Address for correspondence: Dr. Endale Tefera, Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Corner of Zambia and T. Abanefso Roads, P.o. Box 1768, Addis Ababa, Ethiopia. E-mail: endalet[email protected] Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
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Tefera and Bermudez-Cañete: PDA closure in interrupted IVC
a
Figure 1: Aortic angiogram in the lateral projection, showing a patent arterial duct
a
b
b
Figure 2: (a) Terumo wire advanced into the descending aorta through a snared Terumo guide catheter; (b) Delivery sheath advanced over the guide wire into the descending aorta
c
Figure 3: (a) Angiogram through the sheath; (b) Snare capturing the sheath; (c) Device being advanced through the sheath Figure 4: Lateral projection showing aortic disc opened in the descending aorta and sheath freed from the snare
Figure 5: Fluoroscopy in the lateral projection showing device released in the duct
A Terumo catheter was advanced and snared in the descending aorta. An AGA exchange wire (.035” × 260 cm) was advanced through the catheter and snared in the descending aorta. While snaring the wire, an Amplatzer TorqVue 2 delivery sheath 6F, 60 cm long (AGA Medical Corporation, Golden Valley, MN) was advanced over the wire from the venous side and again snared in the descending aorta [Figures 2a and b]. An Amplatzer duct 56
occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare [Figure 3a-c]. The device was opened, again with the sheath still snared. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted [Figure 4]. The device was then released and it attained a stable position [Figure 5]. An aortic angiogram was done after the device was released, showing complete occlusion. The patient remained stable and there was no hemodynamic instability anytime during the procedure. She was extubated immediately.
DISCUSSION Interruption of the inferior caval vein with azygos continuation or drainage into the portal vein or hepatic venous plexus significantly adds technical challenges to percutaneous interventions performed through the femoral vein approach.[2-5] Some of the difficulties that can be encountered include: Kinking of catheters, failure to advance the delivery sheath, and kinking at the Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
Tefera and Bermudez-Cañete: PDA closure in interrupted IVC
Azygos-superior vena-cava junction and right ventricular outflow tract.[4]
their gratitude to all the staff of the cardiac center and the Spanish mission members.
Akhtar and co-workers reported closure of a patent arterial duct through a right internal jugular vein approach in a patient with interrupted inferior caval vein and blood flow directed to a hepatic venous plexus, [2] whereas Sivakumar and Francis reported having closed a duct through retrograde approach from the aorta with a reversed device position, that is, the aortic disc facing the pulmonary artery and the tubular end facing the aorta.[3] Koh and co-workers used the transarterial approach but with an ADO II device, which has discs on both sides.[6]
REFERENCES
What was done in our patient was similar to the technique reported by Al-Hamash.[4] The most important issues are preparing a long catheter and appropriate snares to establish an arteriovenous loop, which is the key for the success of proper delivery and stability of the device. Even though snaring of wire and delivery catheter (especially shorter sheaths like in the present case) has a significant risk of traction and hemodynamic instability in a long circuitous course, it did not happen in this patient. ADO II device was not available and the size of the PDA seemed too large for such a device. The patient had been given heparin, and so, the right internal jugular vein approach could be dangerous.
ACKNOWLEDGMENTS The authors thank Dr Belay Abegaz, founder of the Children’s Heart Fund of Ethiopia and the cardiac center for enabling pediatric cardiology practice in the country. They also extend
Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
1. Bronshtein M, Khatib N, Blumenfeld Z. Prenatal diagnosis and outcome of isolated inferior vena cava. Am J Obstet Gynecol 2010;202:398.e1-4. 2. Akhtar S, Samad SM, Atiq M. Transcatheter closure of a patent ductus arteriosus in a patient with an anomalous inferior vena cava. Pediatr Cardiol 2010;31:1093-5. 3. Sivakumar K, Francis E. Anomalous inferior vena cava drainage to portal vein offers a challenge to transcatheter ductus arteriosus closure. Pediatr Cardiol 2007;28:416-7. 4. Al-Hamash S. Transcatheter closure of patent ductus arteriosus and interruption of inferior vena cava with azygous continuation using an amplatzer duct occluder. Pediatr Cardiol 2006;27:618-20. 5. Patel NH, Madan TH, Panchal AM, Thakkar BM. Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava. Ann Pediatr Cardiol 2009;2:162-4. 6. Koh GT, Mokthar SA, Hamzah A, Kaur J. Transcatheter closure of patent ductus arteriosus and interruption of inferior vena cava with azygos continuation using an Amplatzer duct occluder II. Ann Pediatr Cardiol 2009;2:159-61. How to cite this article: Tefera E, Bermudez-Cañete R. Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach. Ann Pediatr Card 2014;7:55-7. Source of Support: Nil, Conflict of Interest: None declared
57
Copyright of Annals of Pediatric Cardiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach Endale Tefera1, Ramon Bermudez-Cañete2,3 1 2
Department of Pediatrics and Child Health, Cardiology Unit, School of Medicine, Addis Ababa University and Cardiac Center, Addis Ababa, Ethiopia, Ramon y Cajal University Hospital, Pediatric Cardiology Unit, Madrid, Spain, 3Volunteer Cardiologist, Cardiac Center, Addis Ababa, Ethiopia
ABSTRACT Percutaneous closure of the patent arterial duct in patients with interrupted inferior caval vein poses a technical challenge. A 12-year-old girl with a patent ductus arteriosus (PDA) and interrupted inferior caval vein is described in this report. The diagnosis of interrupted inferior caval vein and azygos continuation was made in the catheterization laboratory. A catheter was advanced and snared in the descending aorta. An exchange wire was advanced through the catheter and snared in the descending aorta. Then, an Amplatzer TorqVue 2 delivery sheath was advanced over the wire from the venous side and again snared in the descending aorta. An Amplatzer duct occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare. The device was opened. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted. The device was then released and it attained a stable position. An aortic angiogram was performed which showed complete occlusion. Keywords: Azygos continuation, device closure, interrupted IVC, patent ductus arteriosus
INTRODUCTION
CASE REPORT
Interruption of the inferior caval vein is a rare anomaly with an estimated incidence of 1 in 5,000 cases.[1] When interruption occurs, there could be azygos continuation or other patterns like blood flow being directed to a plexus of hepatic veins, or anomalous drainage of the inferior caval vein into the portal vein may occur.[2,3] Interruption of the inferior vena cava could make percutaneous closure of an arterial duct a challenging procedure. Various options, including right internal jugular vein approach, retrograde transarterial approach, and the conventional right femoral vein approach have been reported to be successful.[2-4] We report a case of large patent arterial duct with interruption of the inferior caval vein and azygos continuation; the patient underwent successful closure of the ductus through the conventional right femoral vein approach.
A 12-year-old girl who presented with dyspnea on moderate exertion and palpitation since three years was admitted for percutaneous closure of a patent arterial duct. Her infancy and childhood period were unremarkable and without cardiac symptoms. Her weight was 39 kg and height was 149 cm. Her blood pressure was 120/60 mmHg. Peripheral pulses were bounding. Precordial examination revealed active precordium with the point of maximum intensity shifted downward and laterally. There was thrill and continuous murmur over the left second intercostal space. Chest X-ray showed marked cardiomegaly. Electrocardiogram (ECG) showed sinus rhythm with a rate of 80 bpm and left ventricular hypertrophy. Echo showed dilated left atrium, left ventricle, and pulmonary artery, and a patent ductus arteriosus (PDA) of about 6 mm with a continuous leftto-right shunt.
Access this article online Quick Response Code:
Website: www.annalspc.com DOI: 10.4103/0974-2069.126560
Under general anesthesia, arterial access was established through the right femoral artery with a 4F introducer and aortic pressure was measured (86/53 mmHg, mean: 69 mmHg). Then, aortic angiogram was done [Figure 1]. A duct measuring 5 mm was seen. On right heart catheterization, it was found that the inferior caval vein was interrupted and that there was azygos continuation.
Address for correspondence: Dr. Endale Tefera, Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Corner of Zambia and T. Abanefso Roads, P.o. Box 1768, Addis Ababa, Ethiopia. E-mail: endalet[email protected] Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
55
Tefera and Bermudez-Cañete: PDA closure in interrupted IVC
a
Figure 1: Aortic angiogram in the lateral projection, showing a patent arterial duct
a
b
b
Figure 2: (a) Terumo wire advanced into the descending aorta through a snared Terumo guide catheter; (b) Delivery sheath advanced over the guide wire into the descending aorta
c
Figure 3: (a) Angiogram through the sheath; (b) Snare capturing the sheath; (c) Device being advanced through the sheath Figure 4: Lateral projection showing aortic disc opened in the descending aorta and sheath freed from the snare
Figure 5: Fluoroscopy in the lateral projection showing device released in the duct
A Terumo catheter was advanced and snared in the descending aorta. An AGA exchange wire (.035” × 260 cm) was advanced through the catheter and snared in the descending aorta. While snaring the wire, an Amplatzer TorqVue 2 delivery sheath 6F, 60 cm long (AGA Medical Corporation, Golden Valley, MN) was advanced over the wire from the venous side and again snared in the descending aorta [Figures 2a and b]. An Amplatzer duct 56
occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare [Figure 3a-c]. The device was opened, again with the sheath still snared. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted [Figure 4]. The device was then released and it attained a stable position [Figure 5]. An aortic angiogram was done after the device was released, showing complete occlusion. The patient remained stable and there was no hemodynamic instability anytime during the procedure. She was extubated immediately.
DISCUSSION Interruption of the inferior caval vein with azygos continuation or drainage into the portal vein or hepatic venous plexus significantly adds technical challenges to percutaneous interventions performed through the femoral vein approach.[2-5] Some of the difficulties that can be encountered include: Kinking of catheters, failure to advance the delivery sheath, and kinking at the Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
Tefera and Bermudez-Cañete: PDA closure in interrupted IVC
Azygos-superior vena-cava junction and right ventricular outflow tract.[4]
their gratitude to all the staff of the cardiac center and the Spanish mission members.
Akhtar and co-workers reported closure of a patent arterial duct through a right internal jugular vein approach in a patient with interrupted inferior caval vein and blood flow directed to a hepatic venous plexus, [2] whereas Sivakumar and Francis reported having closed a duct through retrograde approach from the aorta with a reversed device position, that is, the aortic disc facing the pulmonary artery and the tubular end facing the aorta.[3] Koh and co-workers used the transarterial approach but with an ADO II device, which has discs on both sides.[6]
REFERENCES
What was done in our patient was similar to the technique reported by Al-Hamash.[4] The most important issues are preparing a long catheter and appropriate snares to establish an arteriovenous loop, which is the key for the success of proper delivery and stability of the device. Even though snaring of wire and delivery catheter (especially shorter sheaths like in the present case) has a significant risk of traction and hemodynamic instability in a long circuitous course, it did not happen in this patient. ADO II device was not available and the size of the PDA seemed too large for such a device. The patient had been given heparin, and so, the right internal jugular vein approach could be dangerous.
ACKNOWLEDGMENTS The authors thank Dr Belay Abegaz, founder of the Children’s Heart Fund of Ethiopia and the cardiac center for enabling pediatric cardiology practice in the country. They also extend
Annals of Pediatric Cardiology 2014 Vol 7 Issue 1
1. Bronshtein M, Khatib N, Blumenfeld Z. Prenatal diagnosis and outcome of isolated inferior vena cava. Am J Obstet Gynecol 2010;202:398.e1-4. 2. Akhtar S, Samad SM, Atiq M. Transcatheter closure of a patent ductus arteriosus in a patient with an anomalous inferior vena cava. Pediatr Cardiol 2010;31:1093-5. 3. Sivakumar K, Francis E. Anomalous inferior vena cava drainage to portal vein offers a challenge to transcatheter ductus arteriosus closure. Pediatr Cardiol 2007;28:416-7. 4. Al-Hamash S. Transcatheter closure of patent ductus arteriosus and interruption of inferior vena cava with azygous continuation using an amplatzer duct occluder. Pediatr Cardiol 2006;27:618-20. 5. Patel NH, Madan TH, Panchal AM, Thakkar BM. Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava. Ann Pediatr Cardiol 2009;2:162-4. 6. Koh GT, Mokthar SA, Hamzah A, Kaur J. Transcatheter closure of patent ductus arteriosus and interruption of inferior vena cava with azygos continuation using an Amplatzer duct occluder II. Ann Pediatr Cardiol 2009;2:159-61. How to cite this article: Tefera E, Bermudez-Cañete R. Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach. Ann Pediatr Card 2014;7:55-7. Source of Support: Nil, Conflict of Interest: None declared
57
Copyright of Annals of Pediatric Cardiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
