Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Because the use of percutaneous intervention is increasing for the closure of the patent ductus arteriosus, the procedure-related complications are also on rise, with migration of the device being most common. The routine practice is to remove the migrated duct occluder device under cardiopulmonary bypass. Amplatzer duct occluder used in a 4-month-old infant dislodged into the descending thoracic aorta. It was removed by the posterolateral thoracotomy under mild hypothermia through juxtaductal aortotomy between the aortic cross-clamps. The use of cardiopulmonary bypass is thus avoided.
From the *Departments of Cardiovascular and Thoracic Surgery and †Cardiology, Postgraduation Institute of Medical Research and Education, Chandigarh, India.
Accepted for publication May 21, 2010.
Address correspondence and reprint requests to Prashant N. Mohite, MS, 294, Sector-15/A, Chandigarh 140015, India. E-mail: email@example.com.
Different types of occluder devises are being used to close patent ductus arteriosus by percutaneous catheter intervention technique. The devices may migrate into the branch pulmonary artery or the aorta. The techniques so far mentioned in the literature use cardiopulmonary bypass to remove the migrated or ill-fitted device. Authors demonstrate innovative technique to remove the migrated device in descending thoracic aorta without using cardiopulmonary bypass.
A 4-month-old female infant who developed signs of congestive heart failure was shown to have 6-mm patent ductus arteriosus on echocardiography. She was electively taken up for percutaneous intervention. Occlusion of the patent ductus with balloon reduces the pulmonary pressures to half the systemic pressures. Therefore, a decision of device closure was made, and Amplatzer duct occluder of appropriate size was deployed into the patent ductus. The check fluoroscopy showed that the device partially dislodged into the distal thoracic aorta (Fig. 1). After several unsuccessful efforts, the stuck device could neither be retrieved nor be pushed into the patent ductus.
Invasive monitoring showed upper body hypertension with significant gradient across the part of descending thoracic aorta where the stuck device was protruding. The distal pulses, though palpable, were feeble. The infant was promptly rushed to the operation theater before significant hemodynamic deterioration. Patent ductus arteriosus was approached through the standard left posterolateral thoracotomy, and the ligature was passed around the ductus. The device could be palpated in the distal thoracic aorta just lateral to the patent ductus. Patient was cooled to 34°C with cooling mattress and air conditioning. After quick and adequate dissection, aortic cross-clamps were applied on descending thoracic aorta, just proximal and distal to the stuck device. The patent ductus was temporarily occluded with the ligature, and vertical aortotomy was done between the cross-clamps. The device was found partly stuck into the ductus and partly floating in the aorta. It was held with artery forceps and was delicately removed (Fig. 2). The aortotomy was promptly closed, and cross-clamps were removed after deairing, which was achieved by loosening the ligature around the ductus. The cross-clamp time was <4 minutes. The patent ductus was then ligated with the nonabsorbable suture.
The infant withstood the hypothermia and the cross-clamping well. The postoperative period was considered uneventful. The continuous murmur disappeared, the peripheral pulses normalized, and the infant was discharged after 5 days.
Surgical closure with ligation, clipping, or cut and closure is the traditional method of patent ductus arteriosus closure. Techniques like thoracoscopic clipping, extrapleural clipping, or ligation with minithoracotomy and interventional catheter techniques have gained popularity because of their less invasive approach, avoidance of surgical scar, and lesser hospitalization.1,2 Percutaneous closure of patent ductus arteriosus with duct occlude devices is a safe and effective technique, and the failures were due to the device migrating into the descending aorta, persistent moderate leakage, or difficulty in the advancement of the device.3,4 Embolization of the device was seen in 3.8% of the cases and occurs more commonly to the pulmonary circulation than to the systemic circulation because of the pressure gradient between them.5
Immediate surgical intervention to remove migrated device is indicated in patients who are hemodynamically unstable. Even in patients who are hemodynamically unstable, immediate surgical intervention is preferred because it facilitates the removal of the device before embolization or the removal of the embolus before inflammatory reaction starts.6 Most of the surgical attempts to remove these devices were done with the aid of cardiopulmonary bypass.6,7 Aydin and Ozisik8 reported removal of the migrated coil from left lower pulmonary artery with the help of fogarty without cardiopulmonary bypass. This approach is not useful for devises migrated into descending thoracic aorta.
In the present article, authors demonstrated successful removal of stuck device in the descending thoracic aorta with the use of mild hypothermia and aortic clamping. This is an innovative and easy approach to remove migrated duct occluder devices without using cardiopulmonary bypass.
Migration of duct occluder device into the descending thoracic aorta is not uncommon. Mild hypothermia is sufficient to handle descending thoracic aorta cross-clamping for a procedure of few minutes like removal of migrated device.
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2.Allen HD, Beekman RH III, Garson A, et al. Pediatric therapeutic cardiac catheterization. A statement for healthcare professionals from the council on cardiovascular disease in the young, American Heart Association. Circulation.
3.Parra-Bravo JR, Cruz-Ramírez A, Toxqui-Terán A, et al. Transcatheter closure of patent ductus arteriosus using the Amplatzer duct occluder in children: initial and one-year results. Arch Cardiol Mex.
4.Parra-Bravo R, Cruz-Ramírez A, Rebolledo-Pineda V, et al. Transcatheter closure of patent ductus arteriosus using the amplatzer duct occluder in infants under 1 year of age. Rev Esp Cardiol.
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6.Atik FA, Jatene FB, Costa PHN, et al. Surgical treatment of coil embolization to the pulmonary artery after an attempt at percutaneous closure of patent ductus arteriosus. Arq Bras Cardiol.
7.Shahabuddin S, Atiq M, Hamid M, Amanullah M. Surgical removal of an embolised patent ductus arteriosus amplatzer occluding device in a 4-year-old girl. Interact Cardiovasc Thorac Surg.
8.Aydin H, Ozisik K. Surgical removal of an embolized patent ductus arteriosus coil from pulmonary artery without cardiopulmonary bypass. Interact Cardiovasc Thorac Surg.