Ann Thorac Surg 2007;83:1177-1179
© 2007 The Society of Thoracic Surgeons
Case Reports
Late Embolization of Amplatzer Patent Ductus Arteriosus Occlusion Device With Thoracic Aorta Embedment
David Michael McMullan, MD*,
Achintya Moulick, MD,
Richard A. Jonas, MD
Cardiovascular Surgery, Children’s National Medical Center, Washington, District of Columbia
Accepted for publication July 19, 2006.
* Address correspondence to Dr McMullan, Cardiovascular Surgery, Children’s National Medical Center, 111 Michigan Ave, Washington, DC 20010 (Email: dmcmulla{at}cnmc.org).
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Abstract
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An 11.5-month-old child was found to have a widely patent ductus arteriosus 8 months after percutaneous Amplatzer device closure of the ductus. Angiography confirmed that the occlusion device had migrated to the descending thoracic aorta. The child underwent surgical removal of the device, which was firmly embedded in the aorta and could not be removed percutaneously.
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Introduction
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Failure of normal physiologic closure of the arterial duct during the newborn period may lead to congestive heart failure and pulmonary insufficiency. Early surgical duct ligation is normally undertaken when pharmacologic therapy with indomethacin fails or is contraindicated. Recently, some centers have begun performing percutaneous duct closure as an alternative to surgical therapy in older infants.
A 3.5 month-old child with dextrocardia, a small secundum atrial septal defect, a patent ductus arteriosus with bidirectional blood flow, and echocardiographic evidence of pulmonary hypertension underwent diagnostic cardiac catheterization. At catheterization, the Qp:Qs was 1.3:1, and the mean pulmonary artery pressure was 40 mm Hg. After the ductus arteriosus was occluded with a 6-mm x 4-mm Amplatzer Duct Occluder device (AGA Medical Corp, Golden Valley, MN), the mean pulmonary artery pressure decreased to 32 mm Hg. Postprocedural echocardiography demonstrated partial occlusion of the ductus arteriosus. He was discharged from the hospital with home oxygen therapy and bosentan.
Echocardiography performed 4 months later demonstrated patency of the ductus arteriosus and suggested persistently elevated pulmonary artery pressures. Three months later, he underwent a second diagnostic cardiac catheterization to further evaluate pulmonary hypertension. At catheterization, it was determined that the Amplatzer occlusion device had embolized into the descending thoracic aorta approximately 2 cm distal to the ductal opening (Fig 1). Percutaneous attempts to recover the device were unsuccessful, and the patient was referred for surgical device removal.
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Fig 1. Arteriogram of a patient 7 months after transcatheter closure of patent ductus arteriosus with an Amplatzer Duct Occluder device. The occluder device embolized and became embedded in the intima of the descending thoracic aorta.
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Working through a left posterolateral thoracotomy, a short patent ductus arteriosus (9-mm external diameter) was noted. The occlusion device was identified in the descending aorta by palpation. After mobilizing vascular structures, clamps were applied to the aortic isthmus, the descending aorta below the level of the device, and the pulmonary artery end of the ductus. The duct was divided at its aortic end, and the pulmonary artery end was oversewn.
The resultant aortotomy was extended anteriorly to provide exposure to the occlusion device. The large distal flange of the device had become embedded in the intimal layer of the aorta, and the device was tightly bonded to the aortic wall by a layer of pannus that had formed. The device was sharply dissected from the pannus. Portions of the pannus were also removed. The medial layer of the aorta was uninvolved. The aortotomy was directly closed in 2 layers, without narrowing the lumen, and the mediastinal pleura was reapproximated. The patient’s postoperative course was uncomplicated.
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Comment
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Percutaneous arterial duct closure was first reported by Porstmann in 1971 [1] and is now widely applied. This case study underscores the importance of careful intermediate-term and long-term clinical follow-up of these patients. Although several studies demonstrate immediate and short-term safety and efficacy of percutaneous duct closure [2], only a few reports describe long-term (>5 years) clinical outcomes [3].
When the utility of transcatheter arterial duct closure is evaluated, it is important to compare the results with those of surgical therapy. Since the first successful ligation of a patent ductus arteriosus 68 years ago [4], countless patients have undergone successful surgical duct closure, most of them with decades of follow-up. In the current era, surgical duct ligation or division is highly effective, with essentially no associated operative mortality [5, 6]. Several retrospective studies comparing the results of surgical versus transcatheter arterial duct closure have suggested that surgical duct closure is more efficacious and generally less costly than transcatheter duct closure [6, 7]. Presently, an ongoing randomized, prospective clinical trial is comparing the efficacy of catheter-based patent foramen ovale closure and standard medical treatment in the prevention of recurrent cryptogenic stroke [8]; but as yet, no randomized prospective trial has compared the outcomes of surgical versus catheter-based closure of the arterial duct. Such a clinical trial is needed to provide patients and their caregivers with the information necessary to give full and informed consent before surgical or catheter-based intervention.
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References
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- Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk PA. Catheter closure of patent ductus arteriosus62 cases treated without thoracotomy. Radiol Clin North Am 1971;9:203-218.[Medline]
- Pass RH, Hijazi Z, Hsu DT, Lewis V, Hellenbrand WE. Multicenter USA Amplatzer patent ductus arteriosus occlusion device trial: initial and one-year results J Am Coll Cardiol 2004;44:513-519.[Abstract/Free Full Text]
- Masura J, Tittel P, Gavora P, Podnar T. Long-term outcome of transcatheter patent ductus arteriosus closure using Amplatzer duct occluders Am Heart J 2006;151:755e7–10.
- Gross RE, Hubbard JP. Landmark article Feb 25, 1939: surgical ligation of a patent ductus arteriosus. Report of first successful case. By Robert E. Gross and John P. Hubbard JAMA 1984;251:1201-1202.[Abstract/Free Full Text]
- Mavroudis C, Backer CL, Gevitz M. Forty-six years of patient ductus arteriosus division at Children’s Memorial Hospital of ChicagoStandards for comparison. Ann Surg 1994;220:402-409discussion 9–10.[Medline]
- Gray DT, Fyler DC, Walker AM, Weinstein MC, Chalmers TC. Clinical outcomes and costs of transcatheter as compared with surgical closure of patent ductus arteriosusThe patent ductus arteriosus closure comparative study group. N Engl J Med 1993;329:1517-1523.[Abstract/Free Full Text]
- Hawkins JA, Minich LL, Tani LY, Sturtevant JE, Orsmond GS, McGough EC. Cost and efficacy of surgical ligation versus transcatheter coil occlusion of patent ductus arteriosus J Thorac Cardiovasc Surg 1996;112:1634-1638discussion 8–9.[Abstract/Free Full Text]
- RESPECT PFO Trial. Available at: http://www.amplatzer.com/us/medical_professionals/respect_trial.html. Accessed May 14, 2006.
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Abstract
Introduction
