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

Cost-effectiveness analysis of different devices used for the closure of small-to-medium-sized patent ductus arteriosus in pediatric patients

Aims:

In this study, we examined the differences in cost and effectiveness of various devices used for the closure of small to medium sized patent ductus arteriosus (PDA).

Setting and Design:

We retrospectively studied 116 patients who underwent closure of small PDAs between January 2010 and January 2015.

Subjects and Methods:

Three types of devices were used: the Amplatzer duct occluder (ADO) II, the cook detachable coil and the Nit Occlud coil (NOC). Immediate and late complications were recorded and patients were followed up for 3 months after the procedure.

Statistical Methods:

All statistical calculations were performed using Statistical Package for the Social Science software. P <0.05 were considered significant.

Results:

We successfully deployed ADO II devices in 33 out of 35 cases, cook detachable coils in 36 out of 40 cases and NOCs in 38 out of 41 cases. In the remaining nine cases, the first device was unsuitable or embolized and required retrieval and replacement with another device. Eleven patients (9.5%) developed vascular complications and required anticoagulation therapy. Patients who had hemolysis or vascular complications remained longer in the intensive care unit, with consequently higher total cost (P = 0.016). Also, the need for a second device increased the cost per patient.

Conclusions:

The cook detachable coil is the most cost-effective device for closure of small-to medium-sized PDAs. Calculations of the incremental cost-effectiveness. (ICE) revealed that the Cook detachable coil had less ICE than the ADO II and NOC. The NOC was more effective with fewer complications.

Left Ventricular Dysfunction after Closure of Large Patent Ductus Arteriosus

Changes in left ventricular dimensions and performance were studied in 43 patients after transcatheter occlusion or surgical ligation of patent ductus arteriosus. The patients were assigned to 2 groups based on their ductal diameter: ≥ 3.1 mm to group A ( n = 27) and ≤ 3 mm to group B ( n = 16). The mean age and weight of the groups were comparable. Before intervention, group A had a significantly larger mean left ventricular end-diastolic diameter than group B, while all patients had normal shortening fraction and ejection fraction. Within 1 month after intervention, left ventricular end-diastolic diameter showed a trend towards regression while shortening fraction and ejection fraction decreased significantly in group A. There were no significant changes in these parameters in group B. Between 1 and 6 months after intervention, left ventricular performance improved in most of the group A patients who were followed up. We conclude that closure of large ductus arteriosus in children leads to significant immediate deterioration of left ventricular performance, which appears to recover within a few months. Echocardiographic study before hospital discharge is recommended in these patients. Serious deterioration of ventricular performance after closure may warrant the use of angiotensin converting enzyme inhibitors.

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 device closure of patent ductus arteriosus without arterial access--single institution experience

OBJECTIVE

Retrospective analysis of feasibility, safety and advantages of device closure of patent ductus arteriosus (PDA) using only venous access.

BACKGROUND

Arterial access for transcatheter device closure of PDA has been a standard practice, but has inherent complications, especially in infants.

METHOD

Records of patients who underwent PDA device closure from 2004 to 2012 were reviewed. Echocardiography was used for patient selection and for assessment of procedural outcome.

RESULT

151 out of 179 patients underwent PDA device closure with venous access alone, weighing 2.2-58 kg with half <10 kg and follow up of 6 months-8 years. Fluoroscopic time ranged from 2.2 to 16 min. Immediate closure was achieved in 146 patients. Two patients had new-onset left pulmonary artery turbulence and one had residual flow.

CONCLUSION

PDA device closure without arterial access can be accomplished safely and effectively in vast majority of patients including infants.

Evolution of a Novel Intraductal Patent Ductus Arteriosus Occlusion Device

Persistence of the ductus arteriosus (DA) after birth leads to the congenital heart disease known as patent ductus arteriosus (PDA). The objective of this study is to develop an evaluation protocol and to propose a new and innovative intraductal design for a PDA occluder in order to conform to the varied morphology of the DA and to overcome the problems associated with devices relying on the anchorage mechanism. The new design, an assembly of 36 planar thermally treated Nitinol wires called Novel Device 36 (ND36), is in the shape of a frustum of a cone with a larger diameter of 12 mm, smaller diameter of 6 mm, and length of 11 mm. In-vitro biomimetic evaluations, namely, hemolysis tests and platelet adhesion studies, were conducted to ascertain the biocompatibility of the thermally treated Nitinol wires. These tests were also conducted on two different dimensions of Dacron fibers, which were to be sutured onto the device to induce thrombogenesis while in the duct, thereby facilitating better occlusion. Flow dynamics tests, which help simulate the dynamic conditions prevalent in the duct, were carried out on the ND36 and a commercially used PDA occlusion device. An analysis of the scanning electronic microscopy images showed no platelet adhesion on the Nitinol wires. The tested wires also showed nearly 0% hemolysis. Dacron fibers 0.2 mm thick and having an area density of 77 GSM proved to be best suited. Comparative analysis carried out with the commercially available Amplatzer duct occluder during the flow dynamics tests showed that the ND36 was capable of effectively occluding the duct as well as remaining stable under the dynamic conditions encountered in the duct. The ND36 has the potential to efficiently serve as a simplistic and cost effective alternative for PDA occlusion.

Preclosure pressure gradients predict patent ductus arteriosus patients at risk for later left pulmonary artery stenosis

The objective of this study was to evaluate the incidence of pre-existing catheterization left pulmonary artery (LPA) gradients and correlation of these gradients with later LPA stenosis after successful patent ductus arteriosus (PDA) occlusion. We performed a single-center review of 130 patients with PDA closure from October 1993 to February 2005. We analyzed the pre-PDA closure LPA pressure gradients at catheterization to determine if these were predictive of late LPA stenosis. On follow-up, a V (max) >2 m/s by echocardiogram (transthoracic echocardiography; TTE) was considered indicative of possible LPA stenosis. Left lung perfusion of <35% was considered diagnostic of significant LPA stenosis. Post PDA closure, possible LPA stenosis by TTE was seen in 8 of 128 patients (6.25%). Seven of these eight had precatheter LPA gradients >7 mm Hg. Five of these had perfusion scans, three of the five had significant LPA stenosis, and two underwent LPA angioplasty. Patients with LPA catheter gradients >7 mm Hg were more likely to have possible LPA stenosis by TTE, significant LPA stenosis by lung scan, and intervention with LPA angioplasty. In conclusion, a preclosure main pulmonary artery-to-LPA pressure gradient >7 mm Hg was found in all patients who developed significant LPA stenosis on follow-up after transcatheter PDA closure. It appears likely that these patients have LPA abnormality rather than stenosis caused by the PDA occlusion device. Patients with preclosure LPA gradients >7 mm Hg should undergo follow-up evaluations for detection of significant stenosis and may require treatment if an important flow abnormality is documented.

Complications after transcatheter closure of patent ductus arteriosus

To evaluate the short- and mid-term results and complications ensuing the transcatheter closure of patent ductus arteriosus (PDA). Between October 1999 and December 2005, 117 patients (34 males and 83 females) underwent attempted percutaneous closure of PDA with a minimum diameter of more than 3 mm. Follow-up evaluations were conducted at 1 day and 1, 3, 6, 12 months after the performance of the transcatheter closure. The median age of patients at catheterization was 11 yr (range, 0.6 to 68 yr), median weight was 30 kg (range, 6 to 74 kg), and the median diameter of PDA was 4 mm (range, 3 to 8 mm). This procedure was conducted successfully in 114 patients (97.4%), using different devices. Major complications were detected in 4 patients (3.4%); significant hemolysis (2), infective endocarditis (1), failed procedure due to embolization (1). Minor complications occurred in 6 patients (5.1%); mild narrowing of the descending aorta (2) and mild encroachment on the origin of the left pulmonary artery (4). Although the transcatheter closure of PDA may be considered to be effective, several complications, including hemolysis, embolization, infective endocarditis, and the narrowing of adjacent vessels may occur in certain cases.

Transcatheter closure of moderate to large patent ductus arteriosus with the Amplatzer duct occluder

OBJECTIVES

To investigate the acute and follow-up results of transcatheter closure of moderate to large patent ductus arteriosus (PDA) with the Amplatzer duct occluder.

METHODS

Between April 2000 and June 2005, 237 patients underwent attempted transcatheter closure of PDA, of whom Amplatzer duct occluder was used in 68 patients with moderate-to-large-sized PDA (45 females, with ages ranging from 56 days to 75 years, median 3.3 years). Moderate to large PDA is defined as ductus diameter > or =2.5 mm (> or =3 mm in early phase of this study) in infants and young children, or > or =4 mm in adolescents and adults. The size of device selected was generally at least 1-2 mm larger than ductus diameter.

RESULTS

The ductus diameter ranged from 2.5 to 8.5 mm (4.1 +/- 1.3 mm). Amplatzer duct occluder was successfully deployed in 66 out of 68 patients. The size of device deployed ranged from 4 to 12 mm (6.3 +/- 1.6 mm). The causes of failure in the 2 patients included calcification of ductus resulting, in failure in advancing a sheath to descending aorta in 1 and kinking of a Cook sheath in the other. Distal embolization of the device occurred several hours later in one. After the device was retrieved percutaneously, the patient was sent to surgery. No other significant complications occurred. In the 3-month follow-up, complete occlusion was achieved in all patients. No patient had left pulmonary artery stenosis.

CONCLUSIONS

Transcatheter closure of moderate-to-large-sized ductus with Amplatzer ductus occluder is effective and safe.

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.

The efficacy and safety of the Amplatzer ductal occluder in young children and infants

BACKGROUND

We have used the Amplatzer ductal occluder for transcatheter closure of large persistently patent arterial ducts, and used our experience to assess the safety and efficacy of the device in young children and infants.

METHODS AND PATIENTS

We used the Amplatzer ductal occluder prospectively in 43 patients with large patent arterial ducts, reviewing our experience to identify any problems or complications.

RESULTS

The procedure proved successful in 42 of the patients. We achieved complete occlusion of the duct in 33 (78.5 per cent) of the patients on the day of insertion. In 6 additional patients, complete occlusion occurred 1 week to 6 months after the procedure. Trivial leaks persisted in 2 patients, while one had a significant residual leak. Problems were encountered in 7 patients. The procedure failed in one, a device was wasted in 2, pulled through in 3, while we experienced kinking of the long Mullins sheath, being unable to retrieve the device, in one patient. Minor complications occurred in 6 patients, finding flow at a peak velocity of 2.2 metres per second in the descending aorta in 2 patients, and at 2.5 metres per second in 2 further patients, and flow at 2.5 metres per second in the pulmonary arteries of two patients. One patient experienced a major complication due to excessive bleeding. Out of the 14 patients suffering adverse events, 13 weighed less than 10 kilograms. This rate of problems and complication in these patients weighing less than 10 kilograms was significantly higher than in the patients weighing more than 10 kilograms.

CONCLUSION

Transcatheter occlusion of moderate to large patent arterial ducts with the Amplatzer ductal occluder device is safe and effective, with a high rate of complete occlusion. Problems and minor complications may be encountered in children weighing less than 10 kilograms. If the device is to be deployed completely in the ductal ampulla, and to avoid descending aortic obstruction, the size of the retention flanges of the occluder should not exceed the largest diameter of the patent arterial duct.

Advantages and disadvantages of coils for transcatheter closure of patent ductus arteriosus

Different coils have been used to close the patient ductus arteriosus (PDA). In small- and moderate-sized PDA, coils are an adequate alternative to surgery and/or to other devices. The aim of the study is to review and discuss the advantages and disadvantages of using coils (excluding PFM coils PFM Medical, Germany) to close PDA. Cambier was the first to successfully close a PDA using a Gianturco coil. To date, thousands of patients worldwide have undergone transcatheter closure of PDA using this or other types of coils. The use of coils is analyzed with regard to costs in comparison with other therapeutic modalities; techniques--anterograde, retrograde approach, selection of coil size--in relation to the size of the PDA and the available sizes of coils; efficacy of the rate of complete occlusion and the need for reocclusion; and safety in relation to embolization rate, other complications including hemolysis, left pulmonary artery LPA stenosis and coarctation. It is concluded that coils are a cheap alternative for the occlusion of PDA in the small-to-moderate PDA. The technique can be learned quite quickly, it has a high rate of complete occlusion, and has an acceptable rate of safety. The disadvantages include a moderate rate of coil embolization and of hemolysis in patients with residual shunt after coil occlusion in large PDAs. When more than one coil is used, the potential for developing LPA stenosis is high.

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.

Surgical emergencies during pediatric interventional catheterization

OBJECTIVE

To determine the incidence of catheter-related surgical emergencies during pediatric interventional catheterization procedures.

STUDY DESIGN

We reviewed all interventional catheter procedures (n = 578) over a 4-year period (April 1996 to April 2000) to determine any complication during interventional catheterization that required surgery within 24 hours after catheterization.

RESULTS

The overall incidence of surgical emergencies was 1.9% (70% confidence limits, 1.5% to 2.7%). Complications that required surgical intervention occurred with balloon dilation (valvuloplasty, angioplasty, n = 4), device deployment (coils, stents, atrial-septal defect devices, n = 5), transhepatic access (n = 1), and atrial transseptal puncture (n = 1). For the majority of interventions, the incidence of surgical emergencies was <4% except for two procedures (conduit and pulmonary artery angioplasty) with limited numbers of patients. There were no surgical emergencies during endomyocardial biopsy, coarctation angioplasty, or balloon atrial septostomy.

CONCLUSIONS

Surgery was required in 1.9% of all interventional catheter procedures. Surgical emergencies occurred during a wide variety of catheter interventions and could not be predicted by the type of procedure performed.

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.

Interventional occlusion of congenital vascular malformations with the detachable Cook coil system

INTRODUCTION

Nonsurgical closure of pathologic vascular communications can be achieved by coil embolization. Different systems used in patients with congenital heart disease (e.g., patent ductus arteriosus) allow controlled release of the devices. However, they are too stiff for coil occlusion of small or tortuous vessels.

METHODS AND PATIENTS

The new detachable Cook coil system combines flexibility with a simple release control mechanism. Five children, age 8 days to 10 years, underwent heart catheterization for interventional occlusion of different vascular malformations (two coronary artery fistulas, two aortopulmonary collaterals, and one hemangioma). The diameter of the vessels varied between 1.8 mm and 3.6 mm and the length between 10 mm and 22 mm.

RESULTS

Up to four 0.018" soft spiral coils were placed as distally as possible in the feeding vessels. In addition, in two patients, one to three J-shaped coils were placed inside and proximal to spiral coils. Positioning of the coils was controlled easily by radio-opaque markers. Counter-clockwise rotation of the delivery wire provided fast and safe detachment without movement of the detached coils. Control angiograms showed complete occlusion of the vessels within 10 minutes after delivery of coils.

CONCLUSION

Interventional closure of vascular malformations can be successfully obtained with the detachable Cook coil system. This system offers safe and controlled placement of coils, and it works rapidly in an uncomplicated manner.

Patent ductus arteriosus equipment and technique. Amplatzer duct occluder: intermediate-term follow-up and technical considerations

Between May 1997 and June 2000, 69 patients, ages 0.1 to 34 years, underwent attempted anterograde transcatheter closure of a patent ductus arteriosus (PDA) using the Amplatzer Duct Occluder (ADO). The ADO is a cone-shaped, self-centering, and repositionable occluder made of nitinol wire mesh. A 5Fr to 7Fr sheath was used for the delivery of the device. The mean PDA diameter (at the pulmonary end) was 4.6 +/- 1.9 mm (range 1 mm-8.5 mm). Sixty-seven of the 69 patients had successful device placement. The mean ADO smallest diameter was 6.9 +/- 1.8 mm (range 4 mm-12 mm). Complete angiographic closure occurred in 62 (92.5%) of 67 patients (95% confidence interval, 88.22%-98.77%). In five patients, there was a trivial residual shunt immediately after the procedure. At 24 hours, color Doppler flow imaging revealed complete closure in all 67 (100%) patients. The unsuccessful attempts occurred in two patients with a small, 1-mm diameter native PDA and residual PDA after surgical occlusion. Fluoroscopy time was 7.6 +/- 1.8 minutes (4 min-18 min). No complications were observed. At a median follow-up of 1.5 years (range 0.25 to 3.2 years), all patients had complete closure without complications. We conclude that transcatheter closure using the ADO is a highly effective and safe treatment for most patients with PDA.

Comparison between the safety profile and clinical results of the Cook detachable and Gianturco coils for transcatheter closure of patent ductus arteriosus in 272 patients

OBJECTIVES

We evaluated the occlusion rate and safety of Cook detachable coils versus Gianturco coils in transcatheter closure of patent ductus arteriosus (PDA).

BACKGROUND

The Cook detachable coil recently was introduced in an attempt to improve the safety of transcatheter closure of PDA.

METHODS

Between January 1994 and September 1998, 272 patients underwent transcatheter PDA closure. Cook detachable coils were used in 137 patients, with a mean age of 43.9 months and weight of 13.8 kg. In 135 patients, Gianturco coils were used, with a mean age of 56.8 months and weight of 17.8 kg. The mean narrowest diameter of the PDA in the Cook detachable coil group was 2.85 mm versus 2.32 mm for the Gianturco coil group.

RESULTS

The Cook detachable coil group was younger and weighed less than the Gianturco group (P < 0.05 and 0.02, respectively). Their narrowest PDA diameter was larger (P < 0.01). Embolization rate was significantly lower in the Cook coil group (9[6.5%] of 137 vs 22 (16.3%) of 135; P = < 0.013). The mean follow-up for the Cook coil group was significantly shorter (0.55 years) than for the Gianturco coil group (1.18 years; P < 0.001). On an intention-to-treat basis, complete occlusion by echocardiography was achieved in 99 (72.3%) of 137 patients in the Cook detachable coil group, which was significantly less than the Gianturco coil group (114 [84.4%] of 135; P = 0.008).

CONCLUSION

Cook detachable coils for transcatheter closures of the PDA are safer than Gianturco coils. Hence, children with large ductal can be treated earlier in life. Short-term complete occlusion rate was lower in the Cook detachable coil group. This rate can be explained by a shorter follow-up time, larger ductal diameter, and the different materials used for the detachable coils.

Recommendations of the British Paediatric Cardiac Association for therapeutic cardiac catheterisation in congenital cardiac disease

The aims of these recommendations are to improve the outcome for patients after, and to provide acceptable standards of practice of therapeutic cardiac catheterisation performed to treat congenital cardiac disease. The scope of the recommendations includes all interventional procedures, recognising that for some congenital malformations, surgical treatment is equally as effective as, or occasionally preferable to, interventional treatment. The limitations of the recommendations are that, at present, no data are available which compare the results of interventional treatment with surgery, and certainly none which evaluate the numbers and types of procedures that need to be performed for the maintenance of skills. Thus, there is a recognised need to collect comprehensive data with which these recommendations could be reviewed in the future, and re-written as evidence-based guidelines. Such a review will have to take into account the methods of collection of data, their effectiveness, and the latest developments in technology. The present recommendations should, therefore, be considered as consensus statements, and as describing accepted practice, which could be used as a basis for ensuring and improving the quality of future care.

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.

Transcatheter occlusion of the patent ductus arteriosus: use of the retrievable coil device

The Cook Retrievable Embolization Coil has been designed to improve delivery and positioning during coil embolization of the patent ductus arteriosus (PDA). We report our experience with the use of this new technique. Twenty-eight patients underwent coil embolization of a PDA using the retrievable system. The median patient age was 4.5 years (range, 2 months to 33 years), median weight 17.2 kg (range, 3.1-100 kg). The mean minimum diameter was 1.1 mm (range, 0.3-3.8 mm). One or two Cook Retrievable Embolization Coils were implanted in each PDA. Successful delivery was achieved in 27 cases. There was no shunt by angiography in 19 of the patients (70%). Color echocardiography documented no shunt in 13 of 17 patients (77%). The retrievable coil system represents a successful method of PDA occlusion with good control of coil positioning and delivery.

Anchoring coil embolization in a high-flow arterial model: a pilot study

PURPOSE

To devise and test an occluding coil anchoring system to improve the safety of coil embolization.

MATERIALS AND METHODS

The anchoring system was attached to Gianturco embolization coils and investigated in 15 pigs. In the short-term studies, one 0.035-inch anchored coil (15-18 cm in length and 7-10 mm in diameter) was placed in the infrarenal portion of the abdominal aorta in each of 12 pigs with use of an 8-F catheter from the carotid approach. Aortography was performed before and up to 4 hours after coil placement. In the long-term studies, 0.028-inch anchored coils (8 cm in length and 5 mm in diameter) were placed in the left femoral and the right carotid arteries in each of three pigs with use of a 6-F catheter positioned from the right femoral approach. One week later, the animals were evaluated angiographically for coil migration and vascular occlusion.

RESULTS

Radiographically, the coils created a compact conglomerate on placement in all but one of the animals. No coil migration was noted during follow-up. Necropsy confirmed compact arrangement of the coils within the vessels and revealed effective anchoring of the device in all cases.

CONCLUSIONS

The anchoring coil has proved effective in making coil embolization safer, especially in a high-flow arterial model.