Pulmonary artery size and flow disturbances after patent ductus arteriosus coil occlusion

Fate of the Left Pulmonary Artery and Thoracic Aorta After Transcatheter Patent Ductus Arteriosus Closure in Low Birth Weight Premature Infants

Transcatheter patent ductus arteriosus closure (TCPC) is an emerging treatment for low birth weight extremely premature neonates (EPNs). Left pulmonary artery (LPA) and descending aorta (DAO) obstruction are described device-related complications, however, data on mid- and long-term vascular outcomes are lacking. A retrospective analysis of EPNs who underwent successful TCPC at our institution from 03/2013 to 12/2018 was performed. Two-dimensional echocardiography and spectral Doppler velocities from various time points before and after TCPC were used to identify LPA and DAO flow disturbances. A total of 44 EPNs underwent successful TCPC at a median (range) procedural weight of 1150 g (755-2500 g). Thirty-two (73%) patients were closed with the AVP II and 12 (27%) with the Amplatzer Piccolo device. LPA and DAO velocities on average remained within normal limits and improved spontaneously in long-term follow up (26.1 months, range 1-75 months). One patient, who had concerning LPA flow characteristics immediately after device implant (peak velocity 2.6 m/s) developed progressive LPA stenosis requiring stent placement 3 months post-procedure. In the remaining infants, including 7 (16%) who developed LPA and 3 (7%) who developed DAO flow disturbances (range 2-2.4 m/s), all had progressive normalization of flow velocities over time. TCPC can be performed safely in EPNs with a low incidence of LPA and DAO obstruction. In the absence of significant progressive vascular obstruction in the early post-procedure period, mild increases in LPA and DAO flow velocities tend to improve spontaneously and normalize in long-term follow-up.

Long-term follow-up is not indicated after routine interventional closure of persistent arterial ducts

BACKGROUND

Little is known about the necessity for long-term follow-up after interventional closure of persistent arterial duct (PDA). Potential side effects and complications include residual shunts, haemolysis, device embolization, and obstruction to flow in the adjoining vessels.

METHODS

Single centre retrospective study of paediatric patients undergoing interventional PDA occlusion.

RESULTS

315 patients who underwent interventional occlusion of a PDA between November 2002 and September 2013 were included. Of these, eight needed re-intervention (three for device embolization, five for residual shunt). Seven had mild obstruction to flow in the adjoining vessels, but did not require any intervention. All sequelae were found latest at the first follow-up appointment after the procedure (usually within 3 months); whilst none developed during further follow-up.

CONCLUSION

Complications of interventional closure of PDA were apparent immediately after the procedure or by three months of follow-up. Long-term follow-up is not indicated in cases when no complications are seen early after the procedure.

Long-term follow-up results of lung perfusion studies after transcatheter closure of patent ductus arteriosus

OBJECTIVE

This study presents the long-term follow-up of patients who developed left lung perfusion (LLP) abnormalities following patent ductus arteriosus (PDA) closure with various device types.

DESIGN

The study includes 23 adult and pediatric patients who had undergone transcatheter PDA closure and were shown to have decreased LLP (<40%) by the first scintigraphy performed within the average follow-up period of 14.0 ± 8.12 months (2.0-30 months). For PDA closure, the Amplatzer duct occluder was used in 12 patients, and coils were used in 11. Within the average period of 58.91 ± 12.93 months (37-85 months) after transcatheter PDA closure, a second lung perfusion scintigraphy was performed.

RESULTS

In 13 out of 23 patients (56.5%), LLP improved by the time of the second scintigraphy. Improved and unimproved patients did not differ with regard to age, weight, body surface area, PDA diameter, ampulla diameter, and PDA length at the time of PDA closure and the second scintigraphy. There was no significant difference with regard to the percent of improved patients between the different device types (P =.88). The left pulmonary artery indexes were also insignificantly different (P =.446). Patients with persistent LLP abnormality had significantly higher average Doppler velocity index [(LPA blood flow velocity--RPA blood flow velocity) / MPA blood flow velocity] × 100 (P =.007) and PDA diameter/length. If Doppler velocity index ≥50% is taken as the cutoff value, it is possible to predict persisting LLP abnormality with 80% sensitivity and 76% specificity. Left lung perfusion abnormality was found to persist in patients with PDA diameter/length ≥0.5 with 80% sensitivity and 92.3% specificity.

CONCLUSIONS

The LLP abnormalities seen after PDA closure with various devices eventually improve to normal in the majority of patients during long-term follow-up. Patients whose PDA length is shorter than its diameter are at risk of developing LLP abnormalities that persist long-term.

Pulmonary perfusion scans following transcatheter patent ductus arteriosus closure using the Amplatzer devices

INTRODUCTION

Obstruction to flow in the left pulmonary artery (LPA) is a well-known complication after transcatheter device closure of patent ductus arteriosus (PDA). This complication has been studied for different devices using lung perfusion radionuclide scintigraphy (LPRS), but not for Amplatzer devices. This study was performed to evaluate the effect of such devices on lung perfusion using LPRS.

METHODS

This is a retrospective study that looked at all patients who had PDA closure using different Amplatzer devices at our center between July 1999 and January 2007. All patients underwent LPRS within 24 hr of the procedure. We compared LPRS with other hemodynamic data obtained by cardiac catheterization and echocardiography. Results are presented as mean ± SD or median and ranges.

RESULTS

A total of 70 patients had PDA closure using an Amplatzer device; median age was 1.8 years (4 months to 75 years) and median weight was 12 kg (5-112 Kg). Nine patients had associated cardiac anomalies. Sixty eight patients had available LPRS. The mean percent of left lung perfusion (LLP) was 42.7% (± 6.7%). Excluding patients with pre-existing LPA stenosis, 17% had abnormally decreased LLP. On hemodynamic measurements, 62 patients had available direct pressure measurements following PDA closure. None had significant increase. No correlation was found with echocardiographic data.

CONCLUSION

PDA closure with Amplatzer family of devices is associated with a relatively significant risk of decreased perfusion to the left lung, mostly mild abnormalities. Comparison with catheterization and echocardiographic measurements showed lack of correlation with LPRS findings.

Further experience with catheter closure of patent ductus arteriosus using the new Amplatzer duct occluder in children

The aim of the present study was to report our additional experience with transcatheter closure of the patent ductus arteriosus in 65 consecutive patients using the new Amplatzer duct occluder. The median patient age was 3.6 years (range 0.2to 12), and the median weight was 10.5 kg (range 4 to 38). The device was a modified Amplatzer duct occluder made of fabric-free fine Nitinol wire net in to 2 very low profile disks with an articulated connecting waist. It is delivered through a 4Fr to 5Fr delivery sheath. The device was permanently implanted in 62 of 65 patients. The mean patent ductus arteriosus diameter (at the pulmonary end) was 3.6 +/- 1.3 mm (range 0.5 to 5.5). The mean device diameter (waist diameter) was 4.2 +/- 1.5 mm (range 3 to 6). Complete echocardiographic closure of the PDA at 1 month follow-up was observed in 61 (98%) of 62 patients. Immediately after the procedure, mild left pulmonary stenosis (peak pressure gradient of 8, 10, and 12 mm Hg) in 3 of 63 patients. Device embolization in 1 patient was the main complication of the procedure. No other complications were observed. In conclusion, catheter closure using the Amplatzer duct occluder II is an effective and safe therapy for most patients with patent ductus arteriosus. Additional studies are required to document its efficacy, safety, and long-term results in a larger patient population.

Transcatheter closure of the patent ductus arteriosus using the new Amplatzer duct occluder: initial clinical applications in children

BACKGROUND

In spite of recent advances in transcatheter management, the occlusion of certain anatomic types of patent ductus arteriosus (PDA), especially in infants and small children, remains a challenge. The aim of the study was to report initial human experience with transcatheter closure of PDA in 25 patients using the new Amplatzer duct occluder (ADO II) (AGA Medical, Golden Valley, MN).

METHODS

The median age of the patients was 3.2 years (range 0.1-5 years), and the median weight was 10.5 kg (range 3-18 kg). The device used is a modified ADO II made of fabric-free fine Nitinol wire net into 2 very-low-profile disks with an articulated connecting waist. Both disks are 6 mm larger than the diameter of the connecting waist. Connecting waist diameters range from 3 to 6 mm.

RESULTS

The mean PDA diameter was 3.6+/-1.3 mm (range 0.6-5 mm). The mean device diameter (waist diameter) was 4.3+/-1.4 mm (range 3-6 mm). Complete echocardiographic closure of the ductus at 1-month follow-up was observed in 24 (96%) of 25 patients. Immediately after the procedure, there was a mild left pulmonary stenosis (Doppler gradient of 15 mm Hg) in 2 of 25 patients. No other complications were observed.

CONCLUSIONS

The ADO II is a promising addition to our armamentarium for PDA closure. Further studies are required to document its efficacy, safety, and long-term results.

Differential pulmonary perfusion scan after percutaneous occlusion of the patent ductus arteriosus: one-decade consecutive longitudinal study from a single institution

Reduced left lung perfusion has been described following percutaneous occlusion of the patent ductus arteriosus (PDA). We aimed to identify the incidence of lung perfusion abnormalities and the associated risk factors in our consecutive series. Between November 1994 and December 2003, 150 procedures were performed on 145 patients, age 4.6 +/- 4 years. Gianturco coil was used in 88.2%, Amplatzer duct occluder in 6.7%, and Rashkind Umbrella in 5.5%. Lung perfusion scan was scheduled within 48 h (LPS-1), at 6-12 months (LPS-2) and later (LPS-3) in the case of persistent abnormalities. Left lung perfusion <40% was considered abnormal. LPS-1 was obtained in 95.8% and was abnormal in 31%. LPS-2, available in 48.2%, returned to normal in 65.7% (p < 0.001). LPS-3, required in 6.2%, was normal in 55.6% (p = 0.07). Identifiable risk factors were low age and height (p < 0.01), higher Q(p)/Q(s) ratio (p < 0.05), and larger PDA size indexed for height (p < 0.001) or body surface area (p < 0.01). The number of coils or loops deployed in the pulmonary end of the PDA did not influence lung perfusion. In conclusion, we describe a high incidence of left lung perfusion reduction following percutaneous PDA occlusion, more likely in the young with large PDA. However, spontaneous recovery usually occurs within a few months.

Pre-existing left pulmonary artery stenosis and other anomalies associated with device occlusion of patent ductus arteriosus

A retrospective analysis was performed on 200 consecutive patients who underwent cardiac catheterization for occlusion of Patent Ductus Arteriosus (PDA) at a single center by a single operator. Four significant anomalies were observed: pre-existing Left Pulmonary Artery (LPA) stenosis, left recurrent laryngeal nerve (LRLN) injury, electrocardiogram (EKG) changes, and aorto-pulmonary (AP) collateral arteries. The observation of pre-existing LPA stenosis, marked EKG changes, and permanent LRLN injury have not been previously reported. Incidence, etiology, and clinical significance of these anomalies are discussed with specific new recommendations for the prevention of LRLN injury and occlusion of AP collaterals.

Guidewire and catheter manipulation without coil placement to close minimal patent ductus arteriosus

BACKGROUND

Transcatheter coil closure (TCC) is safe and effective for most patients with PDA, but coil associated complications may occasionally be encountered. For occlusion of minimal PDA (<1 mm), we employed a closure protocol with guidewire and catheter manipulation.

METHODS

Between April 2000 and September 2004, 38 patients with a minimal PDA were classified into two groups according to the occlusion method at our institution. Group A consisted of 11 patients (age range 0.7 to 3.5 years; mean age 1.6 years) who underwent guidewire and catheter manipulation. Group B consisted of 27 patients (age range 0.5 to 2.7 years; mean age 1.3 years) who underwent TCC of PDA.

RESULTS

In group A (a PDA 0.4-0.9 mm), 9 (82%) patients had successful closure, and two (18%) patients failed the manipulation. No patient had complications during the procedure or follow-up. In group B (a PDA 0.5-0.9 mm), 26 (96%) patients had successful closure and 1 (4%) patient failed the attempt at TCC. No adverse events of coil closure was found during follow-up. Compared to the patients in group B, those in group A differed significantly in terms of procedure time. There were no significant differences in age, sex, body weight, PDA size, fluoroscopy time, success rate, and complication rate.

CONCLUSIONS

Our results indicate that the manipulation is safe and effective for patients with minimal PDA. The manipulation technique can be tried before TCC in patients with minimal PDA.

Obstruction of the Aorta and Left Pulmonary Artery After Gianturco Coil Occlusion of Patent Ductus Arteriosus

We report an unusual case of simultaneous obstruction of the left pulmonary artery and descending thoracic aorta after Gianturco coil occlusion in a 15-month-old boy. The diagnosis was made by echocardiography and cardiac angiography. At surgery, thrombi coating on the protruded parts of the Gianturco coil in the pulmonary artery and aorta were found.

Interventional treatment of patent ductus arteriosus in 2004

In 2004, the interventional treatment of patent ductus arteriosus (PDA) is definitive and curative. In current practice, coils are used for smaller PDA, and devices are employed for larger PDA. Developing technologies offer small improvements in control and results, but do not appear to promise major changes in practice. This review summarizes the current and emerging interventional technologies directed at PDA closures.

Transcatheter closure of patent ductus arteriosus using Gianturco coils in adolescents and adults

We present the short- and intermediate-term results of transcatheter closure of patent ductus arteriosus with Gianturco coils in adolescents and adults. During a 5-year period, 55 patients (44 females, 11 males) with ages ranging from 14 to 72 years (median, 23) underwent attempted transcatheter closure of patent ductus with the Gianturco coils. The diameter of the narrowest segment of the ductus ranged from 0.8 to 7.6 mm (3.9 +/- 1.3 mm). The 55 patients were divided into three groups. Group I consisted of nine patients with a ductal diameter < or = 3 mm, group II consisted of 27 patients with a ductal diameter > 3 mm but < or = 4 mm, and group III consisted of 19 patients with a ductal diameter > 4 mm. Four- to five-loop Gianturco coils were used, which were deployed via retrograde aortic route. Multiple-coil technique was generally applied in group II patients. Balloon occlusion technique in combination with multiple-coil technique was generally used in group III patients. Deployment of coil was successful in 51 patients (93%) but failed in 4. The success rate of coil deployment in group I, II, and III were 100% (9/9), 96% (26/27), and 84% (16/19), respectively. A mean of 1.9 +/- 0.7 coils was deployed per patient. Of the four patients with unsuccessful coil deployment, three underwent surgery and one received implantation with Amplatzer duct occluder. Distal embolization of 21 coils occurred in 10 patients (3 in group II and 7 in group III), from whom 20 coils were retrieved with a gooseneck snare and 1 coil was removed during surgery. The mean diameter of ductus in the 10 patients with distal embolization was significantly larger than that in those without (5.2 +/- 1.4 vs. 3.7 +/- 1.1 mm; P < 0.01). Among the 51 patients with successful coil deployment, immediate complete closure was achieved in 20 (39%), while trivial to mild leak was present in 31 (61%). No significant complications were encountered. After a follow-up period ranging from 5 to 42 months, four patients had a small residual shunt and three underwent a second intervention with complete occlusion. None had left pulmonary artery stenosis documented with Doppler echocardiography. Transcatheter closure of ductus with the Gianturco coils is safe and feasible in the majority of adolescents and adults. Taking high embolization rate in patients with a ductus diameter > 4 mm into consideration, controlled-release coils, Buttoned device, or Amplatzer duct occluder can be a better choice.

Iatrogenic coarctation after coil occlusion of arterial duct

Coil occlusion of a patent ductus arteriosus was performed in an 8.5-month-old girl with a large left-to-right shunt through a wide arterial duct. Post-occlusion echocardiography revealed iatrogenic obstruction of the aorta caused by protrusion of the loops of the Jackson coil into the descending aorta. The problem resolved spontaneously during follow-up.

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.

Transcatheter closure of persistent arterial ducts with different types of coils

BACKGROUND

Different types of coils have been designed for transcatheter closure of persistent arterial ducts. We compared the efficacy and safety of three types of coils: Gianturco coils (Cook), Cook detachable coils (Cook), and Duct Occlud devices (pfm).

METHODS

Sixty-three patients underwent coil occlusion of arterial ducts between April 1995 and July 2000. The mean age and weight were 4.8+/-3.4 years and 16.5+/-7.6 kg, respectively. The results and complications of ductal occlusion among the three types of coils were compared. Kaplan-Meier analysis was used to assess reduction in the prevalence of residual shunt with time, and multiple regression analysis was performed to identify predictors of complete occlusion.

RESULTS

Coil occlusion of persistent arterial ducts that measured 2. 2 +/- 0.8 mm was feasible in 90% (57/63) of patients. Gianturco coils were used in 29, Duct Occlud devices in 16, and Cook detachable coils in 12 patients. The prevalence of residual shunt at 24 hours, 6 months, 12 months, and 24 months was 42%, 20%, 18%, and 14%, respectively. The reduction in prevalence of residual shunt with time tended to be greater when Gianturco coils were used (P =. 067). Logistic regression identified the use of Gianturco coils to be a significant predictor of complete ductal occlusion on follow-up (P =.04). Pull-through of coils occurred in 4.8% (3/63) and coil embolization in 6.3% (4/63). There was no association between the type of coil and the risk of embolization (P = 1.00).

CONCLUSIONS

Transcatheter occlusion of small persistent arterial ducts with coils is safe and effective. There is no advantage of detachable coils (Cook detachable coils and Duct Occlud devices) over nondetachable Gianturco coils in reducing the risk of embolization. Our findings are in favor of the inexpensive, but more effective, Gianturco coils for occluding small arterial ducts of 3 mm or less.

Anterograde coil closure of patent ductus arteriosus using a modified bioptome delivery technique

Three consecutive patients are presented who underwent successful anterograde catheter coil occlusion of a patent ductus arteriosus using a modified bioptome-assisted technique. Two of the three patients were infants and the procedures were performed without the need for arterial access.

Further experience with transcatheter closure of the patent ductus arteriosus using the Amplatzer duct occluder

OBJECTIVE

The aim of this study was to report further experience with transcatheter closure of the patent ductus arteriosus (PDA) using the Amplatzer duct occluder (ADO).

BACKGROUND

The design of previously used devices is not ideal for this purpose, and their use has been associated with several drawbacks, especially in large PDAs.

METHODS

Forty-three patients, aged 0.3 to 33 years (mean 6.4+/-6.7 years), with a moderate to large, type A to E PDA, underwent attempted transcatheter closure using the ADO. The device is a plug-shaped repositionable occluder made of 0.004-in. nitinol wire mesh. It is delivered through a 5F to 6F long sheath. The mean PDA diameter (at the pulmonary end) was 3.9+/-1.2 mm (range 2.2 to 8 mm). All patients had color flow echocardiographic follow-up (6 to 24 months) at 24 h, 1 and 3 months after closure, and at 6-month intervals thereafter.

RESULTS

The mean ADO diameter was 6.1+/-1.4 mm (range 4 to 10 mm). Complete angiographic closure was seen in 40 of 43 patients (93%; 95% confidence interval [CI] 85.4% to 100%). The remaining three patients had a trivial angiographic shunt through the ADO. At 24 h, color flow mapping revealed no shunt in all patients. A 9F long sheath was required for repositioning of a misplaced 8-mm device into the pulmonary artery. The mean fluoroscopy time was 7.9+/-1.6 min (range 4.6 to 12 min). There were no complications. No obstruction of the descending aorta or the pulmonary artery branches was noted on Doppler follow-up studies. Neither thromboembolization nor hemolysis or device failure was encountered.

CONCLUSIONS

Transcatheter closure using the ADO is an effective and safe therapy for the majority of patients with patency of the arterial duct. Further studies are required to establish long-term results in a larger patient population.

[Interventions in congenital heart disease and their sequelae in adults]

The advancements of cardiac surgery over the last decades led to larger numbers of patients with operated congenital heart diseases surviving into adulthood. In Germany it is estimated that over 120,000 adults have operated congenital heart diseases. Five to 7% of them will need yearly hospital admissions. Interventional procedures are additional tools used to treat these patients with various sequelae or residua (Table 1). In the following review we concentrate on 2 different interventional procedures: dilatation and stent implantations for treatment of stenosis and the different devices used for the closure of shunt lesions. For congenital valvular pulmonary stenosis, balloon dilatation is the therapy of choice regardless the age of the patient. Stent implantation for the treatment of peripheral pulmonary stenosis (e.g., after previous systemic pulmonary shunts) can decrease the need for redo surgery, which is accompanied with increased risk. Stent implantations proved also to be useful to treat stenoses after Mustard patch in patients with transposition of the great arteries, after Fontan procedures or dealing with the rare pulmonary venous stenosis. In contrast, dilatation of bioprosthesis and conduit stenosis are not promising. Balloon dilatation of valvular aortic stenosis is an accepted therapy in childhood up to adolescents. Table 2 compares a surgical series including many infants with critical aortic stenosis with a series of balloon dilatation in children and another one in adults regarding lethality, complications, and results. Table 3 illustrates the immediate and late results of balloon dilatation of aortic coarctation in 3 different studies. The high recurrence rate in infants made clinicians refrain from taking this age group for balloon dilatation. In children and adult patients, good results are reported (75% reduction of gradients). The complication rate is low (2.3 to 3.3%) and aneurysm formation rate seldom (1 to 7%). Stenosed aorto-pulmonary collaterals will rarely need balloon dilatation. Surgical closure of atrial septal defect is a low risk procedure with a very low rate of residual shunts (2%). Of the 5 available devices for transcatheter closure of atrial septal defect Type II, only 2 occluders are in use in Germany, the Clamshell and the Amplatzer device. The largest clinical studies of the different systems, their efficacy, complications and residual shunt rate are presented in Table 4. For the deployment of these occluders a TEE is always needed. There are many more systems in clinical use to close the patent arterial duct (PDA) (Table 5). The Ivalon plug as well as the Rashkind device have probably only historical value. Different types of coils (Gianturco, Cook detachable, PFM) are now in use worldwide. The reason for their widespread use, besides their easy application, is the fact that most coils are relatively cheap and need only small sheaths for deployment. Their further evaluation identified a residual shunt rate of 5% as well as a number of complications (embolization, hemolysis, stenosis of the left pulmonary artery) in 0 to 6%. For the large PDA the Amplatzer device has recently been introduced. An additional indication for the use of the different occluding devices are aorto-pulmonary collaterals, venovenous fistulae, pulmonary or coronary artery fistulae. Aorto-pulmonary collaterals are often associated with complex cardiac lesions and occasionally appear after palliative procedures. An excellent cooperation between adult and pediatric cardiologists is needed in order to offer the group of adults with congenital heart diseases an adequate and comprehensive management.

The snare-assisted technique for transcatheter coil occlusion of moderate to large patent ductus arteriosus: immediate and intermediate results

OBJECTIVES

The purpose of this study was to evaluate the feasibility, safety and efficacy of using a snare-assisted technique to coil occlude the moderate to large size patent ductus arteriosus (PDA).

BACKGROUND

Transcatheter occlusion of small PDAs using Gianturco coils is safe and effective. However, in larger size PDAs and/or those with short PDA length, the procedure still carries risks of coil embolization, incomplete occlusion and failure to implant the coil.

METHODS

From January 1994 to June 1997, the records of 104 consecutive snare-assisted coil occlusions of moderate to large PDAs (minimum diameter >2.0 mm) were reviewed. Immediate and intermediate outcomes including complete and partial occlusion, failure to implant and complications were analyzed with respect to ductal type and size.

RESULTS

Patient age ranged from 0.1 to 70.1 years (median 3.3 years). Minimum PDA diameter ranged from 2.1 to 6.8 mm (mean 3.0 +/- 0.9 mm). Angiographic types were A-62, B-13, C-6, D-14 and E-9. Using the snare-assisted technique, coil placement was successful in 104/104 patients (100%), irrespective of size or angiographic type. Immediate complete closure was observed in 73/104 (70.2%) and was related to smaller PDA size, but not to angiographic type. Complete closure was documented in 102/104 (98.1%) at 2- to 16-month follow-up. Successful closure was unrelated to PDA size or type. Coil embolization to the pulmonary artery occurred in 3/104 (2.9%) patients and was not related to PDA size or type. The need for multiple coils was found in 28/104 patients (26.9%), and was related to larger PDA size, but not to angiographic type.

CONCLUSIONS

The snare-assisted delivery technique allows successful occlusion of moderate to large PDAs up to 6.8 mm, irrespective of angiographic type. This technique permits improved control and accuracy of coil placement, and facilitates delivery of multiple coils.

Does ductal occlusion with the gianturco coil cause left pulmonary artery and/or descending aorta obstruction?

Thirty-two patients (median age 4.5 years) underwent transcatheter Gianturco coil occlusion of a patent ductus arteriosus. Transthoracic echocardiography was performed the day after coil placement and at intermediate follow-up (median 8.6 months). Echocardiographic results were compared with angiographic and hemodynamic data obtained during catheterization. Two-dimensional (2D) echocardiography performed the day after ductal occlusion displayed evidence of coil protrusion into the left pulmonary artery in 28 of 31 patients (90%) and into the descending aorta in 17 of 29 (59%). However, pulsed Doppler analysis demonstrated normal left pulmonary arterial flow velocities in 28 of 29 patients (97%) and normal descending aortic flow velocities in 26 of 27 (96%). Pulse Doppler results were corroborated by angiographic and hemodynamic catheterization data, which showed no evidence of adjacent vessel obstruction. Peak Doppler velocities among patients with and without 2D echocardiographic left pulmonary artery or descending aorta coil impingement did not differ significantly. The discrepancy between 2D and pulse Doppler findings did not change significantly at intermediate follow-up. Thus, transcatheter occlusion of the patent ductus arteriosus with properly implanted Gianturco coils does not cause significant obstruction to flow in the left pulmonary artery or descending aorta despite frequently misleading 2D echocardiographic images of coil impingement on these vessels.

Coarctation of the aorta following coil occlusion of a patent ductus arteriosus

A case is described in which coarctation of the aorta develops following coil occlusion of a patent ductus arteriosus with a single Gianturco coil. This finding has yet to be reported in children undergoing this procedure and demonstrates the possibility of its occurrence and brings into question the need for and the duration of antibiotic prophylaxis following coil deployment.