Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 227--229

Hybrid approach for aortic embolization of Amplatzer duct occluder


Sudesh Prabhu1, Shreesha Maiya2, Riyan Shetty3, Keshava Murthy4, Prakash Ramachandra2, Rishi Tiwari1,  
1 Department of Paediatric Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
2 Department of Paediatric Cardiology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
3 Paediatric Critical Care Unit, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
4 Department of Cardiac Anaesthesia, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India

Correspondence Address:
Sudesh Prabhu
Department of Paediatric Cardiac Surgery, Narayana Institute of Cardiac Sciences, Bengaluru . 560 099, Karnataka
India

Abstract

Embolization of the patent ductus arteriosus (PDA) device is a known adverse event of percutaneous PDA closure, which can lead to complications. Embolization can occur into the pulmonary artery or into the aorta. Device embolization can be moderate adverse event (when retrieved percutaneously) or major adverse event (when retrieved surgically). We are describing a hybrid approach for aortic embolization of PDA device when the percutaneous retrieval fails, where device retrieval and PDA ligation can be done through thoracotomy incision, thus decreasing the complications.



How to cite this article:
Prabhu S, Maiya S, Shetty R, Murthy K, Ramachandra P, Tiwari R. Hybrid approach for aortic embolization of Amplatzer duct occluder.Ann Pediatr Card 2020;13:227-229


How to cite this URL:
Prabhu S, Maiya S, Shetty R, Murthy K, Ramachandra P, Tiwari R. Hybrid approach for aortic embolization of Amplatzer duct occluder. Ann Pediatr Card [serial online] 2020 [cited 2020 Sep 25 ];13:227-229
Available from: http://www.annalspc.com/text.asp?2020/13/3/227/285670


Full Text



 Introduction



Embolization of percutaneously placed patent ductus arteriosus (PDA) devices is a known complication, which is defined as a released coil or device that is no longer located in the PDA.[1] As per the definition of adverse events and categorization of the complications encountered, device embolization can either be moderate adverse event (when transcatheter retrieval of embolized device is possible) or major adverse event (when device embolization requires surgical retrieval).[1] Majority of the embolization is to the pulmonary artery (PA) than to the aorta (usually abdominal aorta due to antegrade flow) due to higher aortic pressure.

Most of the instances the embolized device can be retrieved percutaneously, followed by re-device or surgical intervention depending on the cause for embolization [Figure 1]. However, when the percutaneous retrieval fails, then the surgical intervention is required and has higher complication rate.{Figure 1}

We are proposing the hybrid approach for the aortic embolization of PDA device, by which device retrieval and PDA ligation can be done through thoracotomy incision, preventing the need and therefore the complications of laparotomy and retroperitoneal dissection and manipulation of abdominal aorta.

 Case Report



A 3-year-old female child was transferred from peripheral hospital with abdominal aortic embolization of PDA device (Amplatzer ductal occluder, AGA Medical Corporation, Minnesota, USA) after failed percutaneous retrieval attempts.

Child was shifted to hybrid operating theatre and device retrieval was attempted under general anesthesia and endotracheal intubation with full heparinization (4 mg/kg). Retrieval attempts (by engaging the retention screw and snaring) failed due to the orientation of the device and also the device was snuggly fitting into the abdominal aorta [Figure 2]. Hence, surgical retrieval was planned. The option was device retrieval from the abdominal aorta through laparotomy and re-device or surgical PDA ligation through thoracotomy. To prevent laparotomy and its complications, hybrid approach was planned (the idea was to disengage the device from abdominal aorta and mobilize it to proximal thoracic aorta and retain it there till the aorta was looped via thoracotomy).{Figure 2}

The ductus was crossed from the venous (antegrade) route and snared from the femoral artery to form an arteriovenous loop. Over this loop, a 12 mm TyShak® balloon (B. Braun Interventional Systems Inc. Bethlehem, PA, USA) was passed from the venous side. The inflated balloon was used to disengage the device from the abdominal aorta and mobilize it to descending thoracic aorta (DTA). The device re-embolization was prevented by keeping a partially inflated balloon (to allow distal blood flow) in the downstream of DTA through femoral artery guide wire (retrograde) [Figure 3].{Figure 3}

Then, a left thoracotomy was performed. Left subclavian artery, aortic isthmus, DTA, and PDA were dissected and looped using rubber slings. The DTA sling was partially snared to prevent device embolization and the TyShak balloon was deflated and withdrawn. PDA was doubly ligated using silk sutures. Then, the aorta was clamped distal to the subclavian and DTA, and device was retrieved through a small aortotomy, which was closed in 2 layers using 6-0 poly propylene sutures after de-airing. Heparin was reversed with protamine. Hemostasis confirmed and chest closed in anatomic layers with a single pleural drain in situ. The patient was shifted to intensive care unit and was extubated 6 h later and discharged on postoperative day 5. Bilateral femoral arteries and veins were patent at the time of discharge.

Hospital ethics committee waived of the clearance as parental consent was obtained.

 Discussion



Embolization of the PDA device occurs at an incidence of <1%–5% depending on the series[1],[2],[3],[4] and is considered as the most significant complication of PDA device procedure. Majority of the embolization is to the PA system than to the aorta. Device embolization can either be moderate adverse event (when transcatheter retrieval of embolized device is possible) or major adverse event (when device embolization requires surgical retrieval).[1]

The direct complications of the embolized device are sudden loss of cardiac output (when in main PA), sudden strain on the left ventricle with associated increase in the left to right shunt (when in aorta), and ischemic complications such as bowel gangrene and/or renal failure.[2] Then, there are complications associated with percutaneous retrieval of embolized devices,[1] which includes vascular trauma (femoral vessels), compartment syndrome, and tricuspid valve injury (related to repeated retrieval attempts). All of these lead to increased morbidity and mortality, necessitating urgent device retrieval.

When device is embolized into PA and the percutaneous retrieval fails, usually requires median sternotomy PDA ligation and device retrieval with or without cardio pulmonary bypass (CPB).[5] However, failure of percutaneous retrieval in aortic embolization of the device necessitates sternotomy with CPB and deep hypothermic circulatory arrest (DHCA)[5] for arch embolization, aortotomy and retrieval[6] for DTA embolization and abdominal exploration[7] for infradiaphragmatic aorta or its branch embolization.

When the percutaneous retrieval fails, by mobilizing the device to the DTA (from anywhere in the aorta or its branches), it is possible to retrieve the device with simultaneous ligation of the PDA through the standard thoracotomy (hybrid approach). This will prevent additional incisions (sternotomy/laparotomy) and avoids the need of CPB or DHCA and its complications.

Comments

In the cases of aortic embolization of duct occlusion device, when percutaneous retrieval fails, then hybrid approach will allow the device retrieval and PDA ligation through thoracotomy incision, thus decreasing the complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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