Ann Thorac Surg 2001;71:1708-1709
© 2001 The Society of Thoracic Surgeons
How to do it
Aortic stent-graft for patent ductus arteriosus in adults: the aortic exclusion technique
François Roques, MDa,
Jean-Luc Hennequin, MDa,
Bruno Sanchez, MDa,
Alex Ridarch, MDb,
Hervé Rousseau, MDc
a Department of Cardiovascular Surgery, Fort de France University Hospital, Fort de France, Martinique
b Department of Radiology, Fort de France University Hospital, Fort de France, Martinique
c Department of Radiology, Toulouse-Rangueuil University, Hospital, Toulouse, France
Accepted for publication December 13, 2000.
Address reprint requests to Dr Roques, Service de Chirurgie Cardio-Vasculaire, CHU de Fort de France, 97200 Fort de France, Martinique, French West Indies
e-mail: f.r.fwi{at}wanadoo.fr
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Abstract
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The risk of closure of a patent ductus arteriosus in the elderly is high because of the fragility of the aorta and aneurysmal change in the ductus. Stent-grafting has emerged as a method of treatment of pathology of the aorta. We describe a case where this new endovascular technique has been successfully applied for closure of a patent ductus arteriosus in a high-risk patient. It may become part of the armamentarium for this pathology in adults.
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Introduction
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Aneurysm formation in a patent ductus arteriosus (PDA) is rare but can be discovered in the elderly [1], in whom the risk of surgical closure is increased as the neighboring aorta is fragile and often calcified. Moreover, in addition to age-related comorbidities, long-standing left-to-right shunt is often associated with pulmonary hypertension or chronic ventricular dysfunction. Today, stent-grafts are proposed as therapeutic alternatives for aneurysm or dissection [2–4]. We report the case of a high risk patient in whom this technique was successfully applied to close the entry of an aneurysmal PDA.
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Technique
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A 65-year-old man was admitted with cardiac failure. Transthoracic echocardiography showed a PDA with a large left-to-right shunt, and left-sided cardiomegaly. On roentgenogram, the thoracic aorta was diffusely calcified. Computed tomography (CT) scan demonstrated a 3.5 cm aneurysm of the PDA (Fig 1A). Pulmonary angiography showed severe compression of the left pulmonary artery by the aneurysm. The pulmonary artery systolic pressure was 65 mm Hg with a substantial left-to-right shunt (pulmonary to systemic flow ratio 2.8, arterial oxygen saturation 93%). Coronary angiography showed nonsurgical three-vessel disease. The patient also had severe chronic pulmonary disease. On aortography (Fig 2A), the PDA arose from the descending thoracic aorta 2.5 cm distal to the origin of the left subclavian artery. This suggested that the release of a stent-graft in order to close the entry of the PDA would not compromise the subclavian artery.
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Fig 1. (A) Computed tomography (CT) scan demonstrating an 3.5 cm large aneurysm of a patent ductus arteriosus ([PDA]surrounded by arrows). The left pulmonary artery is severely compressed, the aorta is calcified. (B) On CT scan 3 months after the procedure, the PDA has disappeared and the left pulmonary artery is widely patent.
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Fig 2. (A) Preoperative angiogram shows the aneurysm of the patent ductus arteriosus ([PDA] surrounded by arrows) and the left to right shunt with immediate pulmonary trunk opacification. (B) Immediate postprocedural angiogram shows the stent graft covering the entry of the PDA without compromising the subclavian artery. The shunt has disappeared.
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Informed consent was obtained. Under general anesthesia, the stent delivery system was inserted into the left femoral artery after open surgical exposure. Under fluoroscopic guidance, the origin of the left subclavian artery was identified with a J-shaped guidewire introduced through the left brachial artery. Biradial and pulmonary pressures were monitored. A custom-made "Talent" stent-graft (World Medical Manufacturing Corp, Sunrise, FL), was released in the aorta in front of the entry of the PDA under a period of a transient hypotension with nitroprusside. Pulmonary systolic pressure immediately dropped from 60 to 35 mm Hg. The left-to-right shunt disappeared and the left subclavian artery remained unobstructed (Fig 2B). Pulmonary angiography demonstrated relief of the left pulmonary artery compression. The patient was well and discharged at day 3. After 3 months the thrombosed aneurysm of the PDA had almost disappeared. and the left pulmonary artery was widely patent. (Fig 1B).
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Comment
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Usually PDAs are treated during childhood. In adults, closure remains indicated to prevent the hemodynamic consequences of large left-to-right shunts and to protect against endocarditis. Surgical division is the procedure of choice. Nevertheless, as the operative risk increases with age, surgery after age 60 becomes questionable [5]. Aortic calcification and PDA aneurysm may lead to surgical difficulties requiring cardiopulmonary bypass and graft replacement of the proximal descending thoracic aorta [6]. Our patient had all these risks in addition to severe comorbidities. Less invasive techniques were therefore considered. Video-assisted thoracoscopic clipping of a large aneurysm was dangerous. Coil embolization is normally reserved for PDAs smaller than 4 mm in diameter and was thus inappropriate. Positioning of an Amplatzer occluder in a large aneurysm would have been difficult. Embolization and occluder placement would have required instrumentation of the aneurysm with the risk of aneurysmal clot embolization (Fig 1A). Deployment of a stent-graft has emerged as an alternative method of treatment of arterial wall defects such as posttraumatic false aneurysm and the entry site of aortic dissection. This had never been electively used for a PDA. To close the inflow of the PDA by this means appeared to us simple and safe. Because the technique respects the integrity of the PDA, it may become the procedure of choice for aneurysmal and calcified PDAs in adults. Whether it will find wider use in other forms of PDA in adults is questionable because of two drawbacks of the method: (1) the diameter of the delivery system (24F) remains too large for patients with small or atherosclerotic iliac arteries; and (2) the distance between the PDA and the subclavian artery must be at least 1.5 cm to allow a safe and efficient deployment of the stent-graft. Still, the uncovered end of the Talent device may overlie the ostium of the artery without compromising it since the wire meshes are large. A dedicated endoprothesis for PDA closure with a miniaturised delivery system may allow more widespread use of this technique in adults.
We report a case of closure of a PDA with an aortic stent-graft. It is simple, safe, and particularly suitable for aneurysmal PDAs. Further improvement in the graft and its delivery system may allow the technique to supersede other nonsurgical procedures in adults.
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References
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Abstract
Introduction
