Follow-up after coil closure of patent ductus arteriosus

Transvenous embolization of moderate to large patent ductus arteriosus in dogs using the Amplatzer vascular plug II

BACKGROUND

Catheter-based occlusion of patent ductus arteriosus (PDA) can be performed using different devices. Transvenous embolization using the Amplatzer vascular plug II (AVP-II) has been studied in humans, but it has not been described in dogs.

OBJECTIVE

Evaluate the feasibility and success of transvenous embolization of PDA using the AVP-II in dogs.

ANIMALS

Nineteen client-owned dogs with left-to-right shunting PDA, with minimal ductal diameter >2.5 mm.

METHODS

Prospective observational study using AVP-II with transvenous access for PDA closure in dogs.

RESULTS

Angiography showed a conical ductus with a long (n = 17) or short (n = 2) ampulla. The minimal diameter of the duct was 4.34 ± 1.11 mm, and the maximal diameter of the ampulla was 13.18 ± 3.47 mm. Technical success was achieved in 18 of the 19 (94.7%) patients after the first intervention and in all 19 (100%) patients after the second intervention. Postrelease angiography documented complete occlusion of the PDA in 10 of 19 (52.6%) dogs. Mild flow acceleration or stenosis of the left pulmonary artery was found in 6 and 1 of the 17 analyzed cases, respectively, by Doppler examination. The closure rate 24 hours after intervention was 94.7% (18/19). The remaining dog had a moderate residual shunt, and delayed complete closure after 3 months led to a 100% closure rate.

CONCLUSION AND CLINICAL IMPORTANCE

The AVP-II is a safe and effective device for transvenous embolization in dogs with moderate to large PDA.

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.

A strategic approach to transcatheter closure of patent ductus: Gianturco coils for small-to-moderate ductus and Amplatzer duct occluder for large ductus

OBJECTIVE

To investigate the effectiveness of the strategy of transcatheter occlusion with the Gianturco coil for small-to-moderate sized ductus and with Amplatzer duct occluder (ADO) for large ductus.

PATIENT AND METHODS

For ductus closure, the following strategy was applied: ADO was used in large ductus: infants and young children weighing < 15 kg with a ductus diameter > or = 3 mm and in older children or adults with a ductus diameter > or = 4 mm and coils were employed in patients with small-to-moderate sized ductus. During a 3-year period, this strategy was applied in 136 patients. The results were compared between 214 patients (group I) undergoing ductus closure using only coil before application of this strategy and strategic closure in 136 patients (group II). Each group was divided into 2 subgroups: subgroup A with large ductus and subgroup B with small-to-moderate ductus. There were 54 patients in subgroup IA, 160 in subgroup IB, 33 in subgroup IIA and 103 in subgroup IIB, respectively.

RESULTS

In group I, PDA occlusion was successful in 207 (96.7%) and failed in 7 (6 of group IA and 1 of group IB). In group II, ductus closure was successful in 134 patients (98.5%) (32/33 with ADO and 102/103 with coils). There was no significant difference in success rate between group I and II. Distal embolization occurred in 19 patients of group I and in 2 of group II, respectively (19/214 vs. 2/136, P < 0.01). There was no significant difference in success rate between group IA and IIA but the distal embolization rate was higher in group IA than IIA (13/54 vs. 1/33, P=0.014). Left pulmonary artery stenosis was found exclusively in 9 patients of group I at the 6-month follow-up (P < 0.05). Nine patients in group I required second intervention to achieve complete occlusion.

CONCLUSIONS

The strategy of ductus closure worked well by reducing embolization rate, incidence of left pulmonary artery stenosis and the need of second intervention.

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.

Comparison of the incidence of residual shunting between two surgical techniques used for ligation of patent ductus arteriosus in the dog

OBJECTIVE

To compare the incidence of residual patent ductus arteriosus (PDA) flow after ligation using 2 different dissection techniques: a standard dissection and a method described by Jackson and Henderson.

STUDY DESIGN

A randomized, prospective study.

ANIMALS

Thirty-five dogs admitted for surgical correction of a left to right shunting PDA.

METHODS

Dogs were randomly assigned: 19 to a standard dissection technique (group S) and 16 to the Jackson and Henderson dissection group (group JH).

RESULTS

Gender ratio, age at surgery, and diameter of the ductus were not statistically different between groups. Breed distribution was also similar. Because 1 dog had fatal intraoperative hemorrhage, only 34 dogs were available for residual flow comparisons. Twenty-one percent of group S dogs had residual flow compared with 53% in group JH. Whereas no intraoperative complications occurred in group S, 3 were encountered in group JH.

CONCLUSIONS

The incidence of residual flow was higher when the Jackson and Henderson dissection was used for PDA ligation compared with a standard method of dissection. This was probably because of entrapment of loose connective tissue within the medial aspect of the ligature, impeding complete closure of the ductus.

CLINICAL RELEVANCE

Ideal PDA closure should result in no residual ductal flow to prevent possible adverse long-term sequelae, such as recanalization and infective endocarditis.

Congenital heart disease in adults: catheterization laboratory considerations

Congenital heart defects are the most common birth defects and represent an increasing proportion of adolescent and adult patients followed by cardiologists. While many of these patients have undergone successful palliative or corrective surgery with excellent functional results, most of them still require careful follow-up. Further, even complex lesions may first be diagnosed in adolescence and adulthood. Therefore, cardiologists caring for adults need to become more familiar with these defects. Assessment of the patient with known or suspected congenital heart defects requires a careful history, physical examination, and noninvasive assessment. In addition, the catheterization laboratory remains a critical venue for diagnosis and, increasingly, therapy. Pressure measurements, oximetry, and angiography remain cornerstones of diagnosis in selected patients and a variety of interventional procedures have become viable therapeutic alternatives in both pre- and postoperative patients.

Transcatheter occlusion of the patent ductus arteriosus: a comparison of two devices

BACKGROUND

Transcatheter occlusion of the arterial duct is a safe and effective alternative to surgical closure. The Rashkind umbrella occluder and the Cook coil are two established devices, although the former is no longer manufactured.

AIMS

To assess any difference in outcomes between the use of the Cook detachable coil and the Rashkind double umbrella in patent ductus arteriosus (PDA) occlusion.

METHODS

A retrospective study of 77 patients in whom PDA occlusion was attempted using the Cook detachable PDA coil from March 1996 to March 2000. A comparison was carried out with patients in whom occlusion was attempted using the Rashkind double umbrella between 1989 and 1996.

RESULTS

The rate of immediate complete occlusion was 24% compared with 29.9% for the Rashkind device. The figure for complete occlusion after 24 hours with the PDA coil was 63% compared with 61.5% in the Rashkind group (p > 0.1). The overall closure rate in the coil group was 72% versus 74.6% for umbrellas.

CONCLUSION

The outcome in terms of complete duct closure using the Cook coil is comparable with figures obtained using the Rashkind umbrella. Both devices have a good safety profile in the short and medium-terms.

Transcatheter occlusion of patent ductus arteriosus using a 0.052-inch coil--immediate results

Coil occlusion of a patent ductus arteriosus (PDA) was attempted with a 0.052-inch Gianturco coil. The patients' ages and body weights at occlusion ranged from 5.8 to 19.7 (12.3+/-5.0, mean+/-SD) years and 18.9-99.1 (44.8+/-23.7) kg, respectively. Three types of 0.052-inch Gianturco coils with loop diameters (mm) and coil lengths (cm) of 6x8 (diameter x length), 8x8, or 8x10 were used. The delivery system was prepared as reported by Hays et al with slight modification. The minimal diameter and the Qp/Qs of the PDA ranged from 2.3 to 4.7 (3.4+/-0.7) mm, and 1.1-1.8 (1.5+/-0.3), respectively. There were 7 cases with type A PDA and 3 with type B, and coils were successfully deployed in all. Complete occlusion in the catheter laboratory was achieved in 4 cases. A minor leak disappeared within 24 h in 3 cases and at 3 months follow-up in 1 case. A tiny leak without a heart murmur persisted in 2 cases at 3 months' follow-up. No procedure-related complications occurred. This technique has significant advantages over previously reported techniques using a 0.038-inch coil for type B, or A PDA with a minimal diameter of 3-4 mm or more.

Interventional catheterization

Several investigations have been performed to evaluate the mid-term results of coil embolization for patent ductus arteriosus. Excellent results were obtained with coils if the minimum diameter of the ductus was less than 4 mm. Balloon dilation of native coarctation and recoarctation may be associated with complications such as aneurysm formation. Stent placement may solve some of the problems of balloon dilation, but the stents currently available are not perfect. Results of transcatheter closure of atrial septal defect using new devices have been were reported. The self-expanding nitinol double-disk device (Amplatzer septal occluder) (AGA Medical Corporation, Golden Valley, Minnesota) is becoming popular because it is easy to implant, is easy to retrieve before its release, can occlude a relatively large defect, and has a low rate of residual leak. Although the immediate results with this device were excellent, surgical closure is still the standard treatment and we need to see the long-term results of transcatheter closure.

Five-loop coil occlusion of patent ductus arteriosus prevents recurrence of shunt at follow-up

Recent reports suggest reopening of the patent ductus arteriosus (PDA) after complete occlusion with three-loop Gianturco coils. We hypothesize that five-loop coils may produce a larger thrombus than three-loop coils, which will result in no or less probability of recanalization of PDA during follow-up. This study is designed to test this hypothesis. Follow-up echocardiographic and Doppler data of 30 patients who underwent five-loop coil occlusion of small to medium-sized PDA during a 33-month period ending December 1998 were examined. Thirty patients had no residual shunt on echo Doppler study on the day following the procedure and were followed for 6 to 30 months (median, 12) after coil implantation. At the last follow-up study, none of the patients had a residual shunt and left atrial size decreased. Careful pulsed, continuous wave, and color Doppler interrogation of left/main pulmonary artery junction and proximal descending aorta did not reveal any evidence for obstruction. The follow-up data suggest that complete occlusion of small- to medium-sized PDAs is feasible with five-loop coils without evidence for recanalization at a mean follow-up of 12 months. Much longer (2 to 5 years) follow-up data may be necessary to confirm these observations. We speculate that a greater degree of thrombosis is produced within the ductus by the five-loop coils, which in turn may be responsible for lack of shunt recurrence. We recommend use of five-loop instead of three-loop coils for transcatheter occlusion of small- to medium-sized PDAs.

Endothelialization of the coils used to occlude a persistent ductus arteriosus: an angiographic study

To assess the endothelialization of the coils used to close a persistent ductus arteriosus (PDA), the present study comprised a review of the follow-up aortograms and pulmonary angiograms in 25 patients who underwent coil occlusion. The minimal diameter and the length of the PDA were measured prior to the procedure, and the shortest distance between the aortic end of the deployed coil and the aortic end of the PDA was measured after coil deployment. Evidence of endothelial coverage of the coil was sought on follow-up angiograms performed 6-24 (15+/-5) months later and the factors that determined the thickness of the endothelial coverage on the aortic end were investigated. Separation of the coil and the contrast column were detected at the aortic end in all cases and at the pulmonary end in 18 of 25 cases. The thickness of the separation ranged from 0.4 to 1.3 (0.7+/-0.2) mm at the aortic end and 0.3 to 0.8 (0.6+/-0.2) mm at the pulmonary end. The length of the ductus and of the ampulla had a significant positive correlation with the thickness of the aortic end separation. Apparent endothelial coverage of the coil was completed by 6 months after coil occlusion. Infective endocarditis or thromboembolism is an unlikely complication once endothelium covers the implanted coil.