Transcatheter closure of patent ductus arteriosus with buttoned device: first successful clinical application in a child

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

Biomaterials and design in occlusion devices for cardiac defects: a review

This review examines the biomaterials used in occlusion devices for cardiac defects, and how the choice of these materials is dictated by design. Specifically, the devices used in three major applications, the atrial septal defect, the ventricular septal defect and the patent ductus arteriosus, are examined critically. A number of different devices are available, with varied performance in deployment and sealing. There is no device in any of the three categories that satisfies fully the range of requirements, and all have associated complications. The type and rate of complications are different among different devices. The short-term (immediate) complications are addressed by immediate retrieval. For longer-term complications, most of which can be fatal, currently only surgical retrieval and replacement are possible. Most of these longer-term complications can be alleviated by the use of fully degradable devices, which will eliminate concerns regarding the use of metals inside the heart, and if fully endothelialized, also minimize migration concerns. On the other hand, the lower moduli of currently available biodegradable materials need to be augmented. Improvements in the stiffness required for deployment can be accomplished with the use of fillers, nano- or micro-sized, and an example of this are radiopaque fillers.

Transcatheter closure of patent ductus arteriosus

More than three decades have passed since the introduction of transcatheter devices for closure of patent ductus arteriosus, and many occluders have been made available since then. The ideal requirements of any procedure are a user-friendly technique, optimum success rate, no residual anomaly, minimal morbidity/mortality, and comparability or superiority to the existing conventional modality of treatment. With various advancements in device design, delivery and assisted systems, the tremendous procedural safety and effectiveness, along with low cost and widespread availability of these devices makes transcatheter closure of patent ductus arteriosus a preferred therapeutic modality in all age groups, with decreasing demographic trends of surgical management.

The results of transcatheter occlusion of patent ductus arteriosus: success rate and complications over 12 years in a single center

Background and Objectives

Percutaneous occlusion of patent ductus arteriosus (PDA) has become increasingly attractive with the evolution of devices and techniques. We reviewed results for percutaneous occlusion of PDA using various devices in a single center.

Subjects and Methods

A retrospective review was done for 118 consecutive procedures performed in 111 patients with PDA between January 1996 and December 2007.

Results

The median age of the patients was 4.5 years (0.9 to 60.3 years); body weight was 16.9 kg (6.8 to 74.7 kg). The median PDA diameter at the pulmonic end was 3.8 mm (0.7 to 10 mm); mean pulmonary artery pressure was 21.0 mmHg (7 to 60 mmHg). Complete occlusion occurred in 76/111 (68.4%) immediately after implantation and in 100/111 (90.0%) at one year of follow-up. Second procedures for residual shunts were done in 7 patients. After the year 2001, the complete closure rate was 95.2% compared to 71.4% before 2001. Complications associated with the procedure were left pulmonary artery narrowing (all <20 mmHg) in 14, arrhythmia in 2, and death in 1.

Conclusion

Evolution of devices, cumulative experience, and health insurance covering the cost of devices have contributed to good outcomes in our center for percutaneous occlusion of PDA. Our results have improved over the years, particularly with the use of the Amplatzer duct occluder.

Transcatheter closure of patent ductus arteriosus and interruption of inferior vena cava with azygous continuation using an Amplatzer duct occluder

Two cases with interrupted inferior vena cava and azygous continuation requiring patent ductus arteriosus (PDA) occlusion per cardiac catheterization are presented. A technique is described enabelmy occlusion of PDA using an Amplatzer ductal occluder despite interruption of inferior vena cava and azygous continuation.

Transcatheter patent ductus arteriosus occlusion: evolution of techniques and results from the 1990s

OBJECTIVE

To review the evolution of transcatheter patent ductus arteriosus (PDA) occlusion techniques and results.

METHODS

A single institution, retrospective review including all patients with intention to close a PDA from 1991 to 1998, with no exclusions.

RESULTS

Rashkind occluder (n = 65), sideris double-button (n = 6), Cook detachable coil (n = 28) and Amplatzer ductal occluder (n = 4) were used. Successful implantation occurred in 99 of 103 patients. There was a need for a second transcatheter procedure to close residual ductal shunting in 12% of patients: Rashkind umbrellas (n = 8), double-button (n = 1), coils (n = 3). Eight patients (8%) required surgery, including 4 of 6 patients with the double-button occluder.

CONCLUSIONS

The Rashkind occluder and the Sideris double-button device both had an unacceptably high rate of residual shunts requiring a second transcatheter procedure or surgical closure. Detachable coils and the Amplatzer ductal occluder have become the current technology of choice for transcatheter PDA closure with high success rates.

Conservative treatment of hemolytic complication following coil embolization in two adult cases of patent ductus arteriosus

Two adult cases of relatively large patent ductus arteriosus (PDA) were treated by coil embolization, but were complicated by hemolysis that was successfully managed by medical treatment. Case 1 was a 67-year-old woman and Case 2 was a 71-year-old woman with a PDA of minimal diameter of 5.3 mm and 5.5 mm, respectively. The approach was via the pulmonary artery and 2 coils were delivered simultaneously into the ductus, known as the 'kissing coil technique'. Although immediately after the procedure only a small residual shunt was revealed by aortogram, hemolysis occurred for several hours after the procedure in both cases. A hemolytic complication usually needs additional coil embolization or surgical treatment, but in these 2 cases it was successfully treated by haptoglobin infusion to prevent nephropathy and by antiplasmin infusion to promote thrombus formation. Hemolytic complications of coil embolization of PDA can managed by medication when the residual shunt is minimal and the degree of hemolysis is mild.

The Sideris buttoned devices for transcatheter closure of patent ductus arteriosus

This article reviews the experience in the last decade with Sideris buttoned devices for occlusion of patent ductus arteriosus (PDA). The devices used were the regular buttoned device, the infant buttoned device, the device with the folding plug, and the wireless device. The buttoned devices were implanted transvenously and introduced through 7Fr-8Fr long sheaths for PDAs up to 12 mm; wireless devices required 9Fr-11Fr sheaths for PDAs up to 22 mm. All different shapes of ductus were occluded. The records of 356 patients in the international and Food and Drug Administration (FDA) supervised United States (US) clinical trials were reviewed. Despite excellent long-term full occlusion rates and the absence of significant complications with the regular buttoned device, modifications were necessary to improve the full occlusion rates in 24 hours. The 24-hour rates improved from 60% with the regular device to 85% with the folding plug device. Most residual shunts disappeared on long-term follow-up without significant complications. Wireless devices were developed for very large PDAs and have excellent occlusion rates. The buttoned device with the incorporated folding plug and the wireless devices are currently under clinical trial. The safety record of the new devices needs to be established with larger clinical trials.

Interventional pediatric cardiology: device closures

Surgical treatment of various septal defects has been long established. With the advances in transcatheter therapy dilatation techniques for valvular stenosis and vascular obstruction have become established procedures. Closure of septal defects in the catheterization laboratory has also been introduced; some of these have come into regular use in current practice. In 1967, Porstmann et al reported the use of Ivalon plug to close patent ductus arteriosus (PDA). Since then, several devices have been used including Rashkind PDA ocluder (not being used now), Gianturco coils, detachable coils (for small PDA), CardioSEAL and other umbrella devices and Amplatzer PDA occluder. Closure rates vary from 95-98% in most series, however, some of these devices are very expensive, more so, when compared to the cost of surgical ligation of PDA. Catheter closure of secundum atrial septal defect (ASD) has also been done by various devices like clamshell device, Sideris Buttoned device, ASDOS device, Amplatzer device and cardioSEAL. So far no device has been accepted as ideal for every case, however, Amplatzer device has been used most extensively. Issues such as completeness of endothelialisation, incidence of late arrhythmias, endocarditis remain uncertain. However, in select population of ASD cases with a central secundum defect, device closure is being used increasingly. Device closure of ventricular septal defect remains challenging and controversial and is probably available to a small group of children with defects that are difficult to close surgically and involve higher risk.

Evaluation of in vivo biocompatibility of different devices for interventional closure of the patent ductus arteriosus in an animal model

OBJECTIVE

To evaluate the in vivo biocompatibility of three different devices following interventional closure of a patent ductus arteriosus (PDA) in an animal model.

MATERIALS AND METHODS

A medical grade stainless steel coil (n = 8), a nickel/titanium coil (n = 10), and a polyvinylalcohol foam plug knitted on a titanium wire frame (n = 11) were used for interventional closure of PDA in a neonatal lamb model. The PDA had been maintained by repetitive angioplasty. Between one and 278 days after implantation the animals were killed and the ductal block removed. In addition to standard histology and scanning electron microscopy, immunohistochemical staining for biocompatibility screening was also undertaken.

RESULTS

Electron microscopy revealed the growth of a cellular layer in a cobblestone pattern on the implant surfaces with blood contact, which was completed as early as five weeks after implantation of all devices. Immunohistochemical staining of these superficial cells showed an endothelial cell phenotype. After initial thrombus formation causing occlusion of the PDA after implantation there was ingrowth of fibromuscular cells resembling smooth muscle cells. Transformation of thrombotic material was completed within six weeks in the polyvinylalcohol plug and around the nickel/titanium coil, and within six months after implantation of the stainless steel coil. An implant related foreign body reaction was seen in only one of the stainless steel coil specimens and in two of the nickel/titanium coil specimens.

CONCLUSION

After implantation, organisation of thrombotic material with ingrowth of fibromuscular cells was demonstrated in a material dependent time pattern. The time it took for endothelium to cover the implants was independent of the type of implant. Little or no inflammatory reaction of the surrounding tissue was seen nine months after implantation.

Follow-up results of transvenous occlusion of patent ductus arteriosus with the buttoned device

OBJECTIVES

The purpose of this presentation is to document results of buttoned device (BD) occlusion of patent ductus arteriosus (PDA) in a large number of patients with particular emphasis on long-term follow-up in an attempt to provide evidence for feasibility, safety and effectiveness of this method of PDA closure.

BACKGROUND

Immediate and short-term results of BD occlusion of PDA have been documented in a limited number of children.

METHODS

During a six-year period ending August 1996, transcatheter BD closure of PDA was attempted in 284 patients, ages 0.3 to 92 years (median 7) under a protocol approved by the local institutional review boards and FDA with an investigational device exemption in U.S. cases.

RESULTS

The PDAs measured 1 to 15 mm (median 4) at the narrowest diameter; 20 were larger than 8 mm and 10 larger than 10 mm. They were occluded with devices measuring from 15 to 35 mm delivered via 7F (N = 140) or 8F (N = 144) sheaths. Successful implantation of the device was accomplished in 278 (98%) of 284 patients. The Qp:Qs decreased from 1.8+/-0.6 (mean+/-SD) to 1.09+/-0.19 (p < 0.001). Effective occlusion defined as no (N = 167 [60%]) or trivial (N = 79 [28%]) residual shunt was achieved in 246 (88%) patients. All types of PDAs, irrespective of the shape (conical, tubular or short), size (small or large) or length (short or long) of the PDA and previously implanted Rashkind devices, could be occluded. Follow-up data, 1 to 60 months (median 24) after device implantation, were available in 234 (84%) patients. Seven (3%) patients required reintervention to treat residual shunt with (N = 2) or without (N = 5) hemolysis. Actuarial reintervention-free rates were 95% at 1 and 5 years. There was gradual reduction of actuarial residual shunts and were 40%, 28%, 21%, 14%, 11%, 10%, 6% and 0% respectively at 1 day, 1, 6, 12, 24, 36, 48 and 60 months after device implantation. Incorporation of folding plug over the button loop in 10 additional patients produced immediate and complete occlusion of PDA.

CONCLUSIONS

This large multiinstitutional experience confirms the feasibility, safety and effectiveness of buttoned device closure of PDAs. All types of PDAs irrespective of the shape, length and diameter can be effectively occluded. Incorporation of folding plug over the button loop produces complete PDA occlusion at the time of device implantation.

Transcatheter occlusion of patent ductus arteriosus with a new detachable coil system (DuctOcclud): a multicenter clinical trial

A multicenter clinical trial of DuctOcclud, a new detachable coil for transcatheter occlusion of patent ductus arteriosus (PDA), was conducted. DuctOcclud was used in 35 patients (12 male and 23 female) for transcatheter occlusion of PDA between January, 1996, and April, 1997. The age of the patients ranged from 0.5 to 27.2 years (median 7.6 years) and weight from 6.3 to 70.0 kg (median 23.0 kg). The smallest diameter of PDA was 2.0+/-0.7 mm (range 1.0-3.3 mm). Pulmonary-systemic flow ratio (Qp/Qs) was 1.3+/-0.3 (range 1.0-2.2). The coils were successfully implanted in 32 (91%) patients. Of 31 patients who were followed 6 months after the procedure, 26 (84%) had no residual shunt and 5 (16%) had trivial residual shunt. One patient had infective endocarditis 1 month after the procedure but recovered completely. There were no incidences of coil embolization, hemolysis, late coil migration, or pulmonary artery stenosis. We conclude that DuctOcclud is a safe and effective device of transcatheter occlusion of PDA.

Transcatheter closure of patent ductus arteriosus in children weighing < 10 kg with Gianturco coils using the balloon occlusion technique

We evaluated the immediate and intermediate follow-up results of transcatheter closure (TCC) of patent ductus arteriosus (PDA) using Gianturco coils in children weighing < 10 kg. The results of PDA < or = 2.5 mm (group I, n = 18) and > 2.5 mm (group II, n = 16) were compared. Coils were deployed sequentially by transarterial route using a temporary balloon occlusion technique. The immediate clinical success rate in both groups was comparable. There was no significant difference in the number of coils required per patient and in the embolization rate between the two groups. Both groups had comparable occlusion rates at intermediate-term follow-up. At intermediate follow-up, one patient had developed left pulmonary artery stenosis while obstruction of the descending aorta was not seen in any; in 4 children the PDA had recanalized. Spontaneous reocclusion was observed in 3 of the latter at the last follow-up. We conclude that TCC of PDA is feasible and safe in children weighing < 10 kg with gratifying intermediate-term results.

Double-helix coil for occlusion of large patent ductus arteriosus: evaluation in a chronic lamb model

OBJECTIVES

We sought to evaluate the efficacy and tissue reaction of a new miniature interventional device for occlusion of large patent ductus arteriosus (PDA) in a neonatal lamb model.

BACKGROUND

A variety of devices are used to close PDAs by interventional measures. Spring coils found to have a high cumulative occlusion rate have thus far been limited to smaller PDAs because of the physical limitation of grip forces.

METHODS

Memory-shaped double-cone stainless steel coils with enhanced stiffness of the outer rings by a double-helix configuration were mounted on a titanium/nickel core wire. A snap-in mechanism attaches the coil to the delivery wire, allowing intravascular coil retrieval and repositioning. The system was placed through a 4F or 5F Teflon catheter. A chronic lamb model (n = 8) of PDA (>5 mm) was used in which ductus patency was secured by a protocol of repetitive angioplasty procedures. The animals were killed after 1 to 181 days, and the ductal region was examined by inspection as well as by light and electron microscopy.

RESULTS

Placement of the coils within the PDA was possible in all lambs. Before final detachment, the coils were retrieved or repositioned, or both, up to 12 times. In all but one animal the ductus was closed within 6 days after the procedure. The coils caused no infections or aortic and pulmonary artery obstruction. Histologic and electron microscopic studies revealed endothelial coverage of the implants but no foreign body reaction or local or systemic inflammation or erosion of the implant.

CONCLUSIONS

The device effectively closed large PDAs in our model and may overcome the previous limitations of coils. Clinical trials are indicated.

Retrievable patent ductus arteriosus plug for interventional, transvenous occlusion of the patent ductus arteriosus. Evaluation in lambs and preliminary clinical results

RATIONALE AND OBJECTIVES

The clinically most widely used devices (Porstmann-plug, Rashkind-umbrella, Botallooccluder) have inherent specific limitations (eg, transarterial approach, residual shunts, limited retrieval). The authors assess practicability, efficacy, and tissue reaction of the new retrievable transvenous plug device for the occlusion of the persistent patent ductus arteriosus (PDA).

METHODS

A foam plug (polyvinyl alcohol) is mounted on a titanium core pin where, at both ends, small legs (titanium nickel alloy) with titanium heads are anchored, to ensure safe fixation in the ductus. The device is introduced transvenously through a long sheath (Mullins sheath) and held by a modified biopsy forceps allowing complete retrieval until final release. A common lamb model of large PDAs (n = 11) was used to test for practicability and the histomorphologic outcome. Clinical results were obtained from a consecutive series of 16 patients (aged 13 to 71 years).

RESULTS

In all lambs, placement of the plug within the PDA was possible. Histopathology (follow-up 10 to 215 days; mean 112 days) revealed an adequate ingrowing of the device and no pathologic foreign body reaction. The diameter of the human PDAs ranged from 3 to 7 mm (mean 5 mm). The size of the sheath used for introducing the plug (diameter 8 to 16 mm) ranged from 8 to 16 French. Fourteen of 16 PDAs were closed immediately after or on day 1 after implantation, 1 was closed after the 12-month follow-up, and 1 needed an additional plug after 30 months for definitive closure.

CONCLUSIONS

The device demonstrated practicability and biocompatibility in our experimental lamb model and effectively closed the PDA in a consecutive series of 16 patients. A greater number of patients and a longer follow-up period are necessary for the definitive clinical assessment of the new device.

Transcatheter occlusion of patent ductus arteriosus using coil embolization

We studied 31 procedures of coil embolization for occlusion of ductus arteriosus, attempted in 29 patients. The mean age was 4.8+/-3.4 years (1-16 years) and the mean diameter of ductus was 1.8+/-0.7 mm (0.8-3.1 mm). Femoral artery approach was used and aortogram in 90 degrees lateral view was performed. Through a Judkin right coronary catheter, the coil was delivered for occlusion of the ductus. In 5 cases, 2 coils were delivered using retrograde and anterograde techniques. Successful placement of coil was accomplished in 29 procedures. Coils 0.038 inch (diameter)-5 cm (length)-5 mm (helical diameter) (Cook, Inc) were used in 16 procedures, coils 0.035 inch-5 cm-5 mm in 9, coil 0.038 inch-8 cm-8 mm in 1, two coils 0.038 inch-5 cm-5 mm in 2, coils 0.038 inch-5 cm-5 mm+0.038 inch-5 cm-8 mm in 1, and 2 coils 0.035 inch-5 cm-5 mm in 2. Aortogram 20 min after the occlusion, showed residual shunt in 9. Coil migration occurred in a ductus type B in the following day. One patient developed severe haemolysis, due to a change in the coil position, 12 h after the procedure. Echodopplercardiogram 4 to 6 h after the procedure showed a residual shunt in 5 patients, 24 h after in 3 and 30 days after, in 1(3.8%). Heparin therapy started 10 days after occlusion of the ductus, caused reappearance of the shunt in 1 patient. This technique is simple and effective, but complications may occur hours or days after successful ductus occlusion.

New technique using temporary balloon occlusion for transcatheter closure of patent ductus arteriosus with Gianturco coils

We describe our early experience with a new technique involving temporary balloon occlusion for transcatheter closure of patent ductus arteriosus (PDA) using single or multiple Gianturco coils. Coil occlusion was attempted in 21 patients of median age 3 (range 1-11) years, and angiographic PDA diameter 3.0 mm +/- 0.87 mm. The inflated balloon of a pulmonary wedge pressure catheter over a transductal wire was used to mechanically hold the first extruded loop of the coil at the pulmonary end of the duct. If a residual shunt persisted after the delivery of the first coil, additional coils were delivered with or without the balloon support. One to nine coils (median 2) of different sizes varying between 3-12 mm diameter and 4-15 cm length were used. Immediate angiographic occlusion rate was 47.6%. However color Doppler (CD) at 24 hours and at 6 weeks revealed complete closure in 66.6% and 80.9%, respectively. Blood transfusion was required in 2 (9.5%) patients. Three out of 56 coils (5.4%) embolized during deployment. The use of balloon occlusion is effective and safe in the treatment of ducti up to 4.7 mm. Residual shunts lend to occlude with time.

Percutaneous coil occlusion of patent ductus arteriosus

OBJECTIVE

To determine the success rate and safety of percutaneous patient ductus arteriosus (PDA) coll occlusion.

DESIGN

Thirty consecutive pediatric patients with small to moderate-size PDAs (minimum diameter < or = 4 mm) underwent percutaneous coll occlusion. The results were assessed by angiography and echocardiography. The mean age was 5.1 +/- 4.2 years (range, 0.8 to 18.8 years); mean weight was 19.2 +/- 10.3 kg (range, 8.1 to 40.0 kg). The mean minimum diameter of the PDA was 1.8 +/- 0.8 mm (range, 1.0 to 4.0 mm).

RESULTS

PDA occlusion was achieved with one coil in 24 patients, 2 coils in 3 patients and 3 coils in 3 patients. The mean coil/PDA diameter ratio was 2.5 +/- 0.5. Immediately after coil occlusion, 29 PDAs had no flow by anglography; one had a small residual shunt. There were no significant complications. In the first 24 hours after coil implantation, echocardiography showed complete occlusion in 28 patients, a small left-to-right shunt in the same patient that had a residual shunt by anglography, and a trace shunt in one additional patient. In the two patients with residual flow by echocardiography, follow-up ultrasonography revealed no residual shunt 1 and 3 months later. At a mean follow-up of 11.8 +/- 9.3 months (range, 0 to 36.0 months), there was no PDA flow by color Doppler echocardiography in any of the 30 patients.

CONCLUSION

Coil occlusion is a safe and effective method of percutaneous closure of small to moderate-size PDAs. The largest PDA that can be closed with this technique remains to be determined.

Transcatheter closure of the patent ductus arteriosus: a comparative study between occluding coils and the Rashkind umbrella device

This study was performed to evaluate the efficacy of transcatheter coil closure of the patent ductus arteriosus in comparison to our experience with the Rashkind umbrella device. Transcatheter coil closure of the patent ductus arteriosus has been reported with encouraging results. We present our experience with ducti up to 5.0 mm in diameter and report the short-term follow-up. We compare the results with our previous experience with the Rashkind umbrella device. Seventy-one patients underwent transcatheter coil closure. Median age was 3.1 years, and median weight was 13.6 kg. Mean ductus diameter was 2.0 +/- 1.1 mm. These were compared with 105 patients who underwent transcatheter closure using a single Rashkind umbrella device. The median age was 3.2 years and the median weight was 14.0 kg. The mean ductus diameter for this group was 2.1 +/- 0.6 mm. The ductus murmur in the coil group disappeared in all patients. Immediate (< or = 24h), complete closure was achieved in 89% of the coil group as compared to 71% for the Rashkind umbrella device group (P < 0.005). Closure rate for the coil group was 97% at the 6-month follow-up, vs. 82% for the Rashkind umbrella device group at the 6-12 month follow-up (P < 0.05). In almost all patients requiring more than one coil, the ductus was crossed serially from the aortic end. All patients with ductus diameter > or = 3.0 mm required two or more coils. Eleven coils in six patients embolized to the pulmonary arteries. All coils except one were retrieved with subsequent successful foil placement. Sixty-seven patients (94%) in the coil group were discharged in < or = 24 h. Transcatheter closure of the patent ductus arteriosus using multiple coils is a more effective technique than the Rashkind umbrella closure and has excellent short-term results. This can be performed safely as an outpatient procedure.

Experimental evaluation of a new self-expanding patent ductus arteriosus occluder in a canine model

PURPOSE

A new self-expanding patent ductus arteriosus (PDA) occluder was designed.

MATERIALS AND METHODS

Percutaneous closure of surgically created aortopulmonary shunts was attempted in 19 dogs. The occlusion device consisted of a nitinol wire frame tightly woven into a cylinder with a flat retention disc. A polyester-filled frame was used in the last six procedures. A 6-F introducing sheath was advanced across the aortopulmonary conduit into the descending thoracic aorta. The prosthesis (attached on a stiff delivery cable) was advanced through the introducing sheath. The retention disc was first released in the descending thoracic aorta, then the cylindrical device frame was expanded within the conduit by withdrawing the sheath.

RESULTS

Subtotal misplacement into the descending aorta occurred in one procedure (overall technical success rate, 95%), and one animal died before the 1-week follow-up. Complete angiographic shunt closure was achieved in seven of 18 (39%) animals at 30 minutes, 12 of 17 (71%) animals at 1 week, 14 of 17 (82%) animals at 1 month, and 11 of 12 (92%) animals at 3 months. Significantly higher 30-minute closure rates occurred with polyester-filled occluders compared with nonfilled occluders (five of five [100%] vs one of 13 [15%]; P = .002). Persistent shunt at 3 months occurred in only one nonfilled device (6%). In the remaining 16 animals, both orifices of the shunt were covered by a smooth glistening neoendothelium at postmortem examination.

CONCLUSION

This device combines the advantages of small delivery system, easy placement, self-centering, and repositionability. Immediate shunt closure can be reliably accomplished with the polyester-filled prosthesis.

Transcatheter closure of patent ductus arteriosus using controlled-release coils

Controlled-release coils have become available recently for the closure of patent ductus arteriosus (PDA). Transcatheter closure of patent arterial ducts was attempted in 13 patients, ranging in age from 5 months to 15 years, mean 4.1 years. Implantation of controlled-release PDA coils was attempted via the femoral artery through 5 Fr catheters in all cases except one, in whom both the femoral arterial and venous routes were used. The procedure was successful in 10 of the 13 patients. In these, the pulmonary artery systolic pressure ranged between 25 and 42 mmHg and the duct diameter varied from 1.5 to 6 mm at its narrowest point. Six of the patients received a single coil. Two coils were inserted in three patients and three coils in one patient. In three patients the ducts were too large for safe release of the coils, despite attempted implantation of up to three coils simultaneously. These coils were easily withdrawn into the catheter. Immediately at the end of the procedure, the duct was completely occluded in nine of the 10 patients, and in one patient there was a small residual flow. The procedure time varied between 35 min and 2.5 h, mean 81 min and the fluoroscopy time varied from 5 to 78 min, mean 25 min. None of the patients experienced hemorrhage, diminished lower extremity pulse, hemolysis or infection. In one patient, a 5 mm coil embolized into the right pulmonary artery soon after release. It was retrieved with a snare, then 8 mm and a 5 mm coil were implanted satisfactorily in the arterial duct. At follow-up by color Doppler echocardiography, the duct was completely occluded in all patients. Transcatheter closure of patent arterial ducts by controlled-release PDA coils is effective and safe. Even when more than one coil is inserted, it is still cheaper than transcatheter umbrella closure. This method is therefore of great value, particularly in less affluent countries.

Transcatheter occlusion of patent ductus arteriosus: which method to use and which ductus to close

Many devices have been developed for transcatheter occlusion of PDA. Bulkiness of the device, complexity of the procedure, and significant residual complications make the majority of the devices unsuitable for routine clinical use. Although no randomized comparative clinical trials exist, on the basis of published literature and my personal experience, coil occlusion may be best suited to close small ducts (< or = 3.5 mm) and the adjustable buttoned device may be most appropriate for large PDAs (> 3.5 mm). Clinical trials on larger patient populations than are currently available and long-term follow-up are necessary to further support these recommendations. Indications for transcatheter closure should be exactly as those used for surgical closure: PDA with audible continuous murmur with echo Doppler confirmation. The so-called silent ducts need not be closed.

A small interventional device to occlude persistently patent ductus arteriosus in neonates: evaluation in piglets

OBJECTIVES

We attempted to evaluate the efficacy and tissue reaction of a new miniature interventional ductal occlusion device in neonatal pigs.

BACKGROUND

A variety of devices are used to close persistent ductus arteriosus (PDA) by interventional measures. Because of the size of these devices, they have not been applied to term or preterm neonates. Newborn piglets are comparable in size and fragility to human term and preterm neonates.

METHODS

Memory-shaped double-cone stainless steel coils were mounted on a titanium-nickel core wire. A snap-in mechanism attaches the coil to the delivery wire, allowing intravascular coil retrieval and repositioning. The system was placed through a 3F Teflon catheter. Two piglet models of PDA were used: 1) ductal patency maintained by stents (n = 6), and 2) ductal patency produced by angioplasty (n = 7) to avoid stent-coil interaction.

RESULTS

Placement of the coils within the PDA was possible in all piglets. Before final detachment, the coils were retrieved or repositioned, or both, up to eight times. In all but two piglets the ductus was closed within 1 h of the procedure. The coils were never dislocated and caused no infections or relevant aortic and pulmonary artery obstruction (95% confidence interval for missing complications [0 of 13] extends to 23%). Histologic and electron microscopic studies revealed endothelial coverage of the implants and histiocytic reaction but no local or systemic inflammation or erosion of the implant.

CONCLUSIONS

The device was effective in experimental models of PDA. The information obtained warrants initial trials of the device in neonates.

Coil occlusion of a residual ductus arteriosus remaining after implantation of a buttoned device

A 20-mo-old boy presented with persistence of significant shunt 13 mo after patent ductus arteriosus closure using the Sideris buttoned device. This residual shunt through the ductus arteriosus was successfully occluded using a Gianturco coil.

Occlusion of the neonatal patent ductus arteriosus with a simple retrievable device: a feasibility study

PURPOSE

To examine the feasibility of transvenous placement of a new memory-shaped, small, retrievable coil that has a smaller-caliber delivery system than currently available devices, for closure of the patent ductus arteriosus (PDA).

METHODS

Through 4 or 5 Fr vascular sheaths and 4 or 5 Fr end-hold catheters, the coils were delivered and placed in piglets (n = 10) with PDA. The coils were made from 0.018" (0.46 mm) or 0.028" (0.71 mm) stainless steel guidewire. Mounted for delivery, the new device has the appearance of a conventional guidewire. This neonatal PDA model was created without major surgery or drugs by stenting the ductus arteriosus.

RESULTS

The memory-shaped coils were easily delivered. Coils not optimally placed were retrieved and repositioned. Occlusion of the ductus arteriosus as early as a half-hour after delivery was shown angiographically and confirmed by histopathology.

CONCLUSION

This new, small-caliber, simple device was found to be effective for closure of the PDA in this animal model. Longer-term observations are needed.

Effectiveness of a thermal shape-memory patent ductus arteriosus occlusion coil

A new shape-memory coil for transcatheter closure of the PDA was developed and evaluated in a dog PDA model. The coil is sensitive to temperature (composed of thermal shape-memory nickel-titanium). The coil was delivered to and implanted in the PDA model with a 5F catheter through the femoral artery. The PDA model was made in 14 dogs by infrarenal aorta banding (diameter 2.0 +/- 0.6 mm; length 2.9 +/- 0.1 mm). Coils were implanted in 10 dogs, whereas the other 4 dogs served as controls. Complete occlusion of the PDA model was confirmed by angiography 24 hours after the coil implantation in 7 of 10 dogs, whereas small residual flow was noted even 2 weeks after the coil implantation in the other 3 dogs. The PDA model internal diameter in the dogs with complete occlusion (1.8 +/- 0.2 mm) was significantly smaller than the diameter in dogs with residual flow (2.9 +/- 0.4 mm, P < 0.05). In the 4 control dogs, the PDA model remained patent 2 weeks after the banding. We conclude that the transcatheter occlusion with the shape-memory coil was effective in the small-diameter PDA model.

Transcatheter occlusion of patent ductus arteriosus

This article reviews the current status of transcatheter technology, which has been applied to close the patent ductus arteriosus (PDA). Pioneering work in this field was performed by Porstmann in the 1960s and Rashkind in the 1970s. Devices which have been implanted in the PDA have basic designs as plugs, umbrellas, or coils. The experience reported with each type of device is detailed. Issues and controversies are examined. It appears that coils should be the preferred method for closing smaller PDAs (3-mm diameter or smaller), and Rashkind or similar devices, if available, should be reserved for larger PDAs (> 3-mm diameter). Surgery is necessary for neonatal and for rare large PDAs. Transcatheter technology is still evolving and may become more effective and cheaper.

Transcatheter occlusion of patent ductus arteriosus by Rashkind umbrella device: follow-up results

Seventy-six patients (36 boys and 40 girls) with patent ductus arteriosus who had successful ductal occlusion with a Rashkind umbrella device were monitored for a period of 6 to 60 months (mean 26.7 +/- 12.3 months). All patients were evaluated by pulsed and color Doppler echocardiography before and after the procedure. The prevalence of residual left-to-right shunt and main pulmonary artery flow pattern were assessed. Residual left-to-right shunt was seen in 12 (15.7%) patients 24 hours after the procedure, but the shunt was small with a pulmonary-to-systemic blood flow ratio of < 1.3:1. Repeat echo Doppler study at 14 days showed residual left-to-right shunt in 10 (13.1%) patients. None of these patients showed further decrease in prevalence of residual left-to-right shunt. The patients with residual left-to-right shunt had larger ductii (mean 5.17 +/- 0.88 mm, range 4.23 to 6.6 mm) as compared to patients with no residual left-to-right shunt (3.31 +/- 0.86 mm, range 1.8 to 4.69 mm; p < 0.001). Two patients with residual shunt had successful ductus reocclusion, with 12 and 17 mm devices, respectively, at 28 month of follow-up. The Rashkind umbrella device is effective in closing ducti with diameters of < 5 mm in majority of patients.

Percutaneous closure of the small patent ductus arteriosus using occluding spring coils

OBJECTIVES

This report summarizes our experience with the use of occluding spring coils to close the small patent ductus arteriosus.

BACKGROUND

Several patent ductus arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent ductus arteriosus in a small group of patients. This report describes our series of patients having patent ductus arteriosus closure with occluding spring coils.

METHODS

Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent ductus arteriosus closure by occluding spring coils. Selection criteria were age > 6 months and narrowest patent ductus arteriosus internal dimension < or = 3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent ductus arteriosus and into the aortic diverticulum. Patent ductus arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging.

RESULTS

Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent ductus arteriosus. Average ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent ductus arteriosus noted on color flow imaging. One patient did not have successful implantation. This patient had a 3.2-mm ductus, and two coils migrated to the distal left pulmonary artery and could not be retrieved. There were no deaths or any significant complications noted during early or late follow-up in these patients.

CONCLUSIONS

Occluding spring coils may have additional application in closing the small patent ductus arteriosus.

Transcatheter occlusion of patent ductus arteriosus with Gianturco coils

BACKGROUND

Transcatheter occlusion with Gianturco coils has been attempted in a small number of patients with tiny (< or = 1.5-mm diameter) patent ductus arteriosus, and preliminary results have been encouraging. The present study extends this method to larger ductus sizes and makes recommendations for proper coil size selection.

METHODS AND RESULTS

Coil occlusion was attempted in 24 consecutive patients with patent ductus arteriosus who did not require other cardiac surgery. Median patient age was 4.2 years (8 months to 30 years), and mean ductus diameter was 1.7 +/- 0.8 mm. Two instances of coil embolization occurred in the first 4 patients, with successful coil retrieval. Based on this experience, we proposed that the coil helical diameter should be twice or more the minimum ductus diameter, with coil length sufficient for three or more loops. With these recommendations, coils were successfully implanted in the subsequent 20 consecutive patients. Of the 22 patients with successful coil implantation, 15 (68%) had no residual shunting, and 7 had trace residual shunting by angiography. The continuous murmur was abolished in all 22 patients. No significant complications occurred, and all patients were discharged within 24 hours of successful coil implantation. No change in the systolic pressure gradient between main and left pulmonary artery or ascending and descending aorta was observed.

CONCLUSIONS

Transcatheter occlusion of patent ductus arteriosus can be safely and effectively achieved in patients with ductus diameters up to 3.3 mm. Coil occlusion does not cause obstruction to flow in the left pulmonary artery or descending aorta. Coils should be selected to provide a helical diameter twice or more the minimum ductus diameter and a length sufficient for three or more loops.

Transcatheter occlusion of patent ductus arteriosus with adjustable buttoned device. Initial clinical experience

BACKGROUND

Several devices are available for transcatheter occlusion of patent ductus arteriosus. Most of these devices either require complicated intracardiac maneuvering, have not been tried in humans, or need a large-sized sheath for implantation of the device.

METHODS AND RESULTS

During a 26-month period ending November 1992, 14 patients underwent transcatheter closure of patent ductus arteriosus with an adjustable buttoned device delivered via a 7F sheath under an institutional review board-approved custom-made device protocol. The children were 15 months to 8 years of age with weight range of 7.2 to 19 kg. The patent ductus arteriosus measured from 2 to 7.5 mm (median, 3 mm) at the narrowest diameter and was conical, short, or tubular. They were occluded with devices measuring 15 to 20 mm. The ratio of pulmonary to systemic flow decreased (P < .01) from 1.9 +/- 0.6 (mean +/- SD; range, 1.3 to 3.2) to 1.05 +/- 0.1 (1 to 1.3). Continuous murmur of patent ductus arteriosus disappeared in all except 1 patient. Small residual shunts were detected by color Doppler studies in 4 of 14 patients (29%). All patients were followed for 1 to 24 months (mean, 6 +/- 7 months). The device was intact in all patients, and no breakage of the wires was noted. No shunts were seen in 12 of 14 patients (86%), and minute residual shunts were seen in 2 children. No major complications were encountered.

CONCLUSIONS

It is concluded that transcatheter closure of patent ductus arteriosus with the adjustable buttoned device is feasible and effective and can be accomplished via small 7F sheaths; a 7F sheath is adequate for all ductal sizes; and the adjustable length of the loop accommodated all types of patent ductus arteriosus. Clinical trials on a larger number of patients are warranted.