|Year : 2018 | Volume
| Issue : 1 | Page : 56-58
Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava
Anil R Jawahirani1, Mahesh Fulwani2, Pushkaraj Gadkari2, Sanjay Gidhwani2
1 Department of Cardiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Cardiology, Shrikrishna Hrudayalaya and Critical Care Center, Nagpur, Maharashtra, India
|Date of Web Publication||24-Aug-2018|
Dr. Anil R Jawahirani
Department of Cardiology, Jawaharlal Nehru Medical College, Sawangi, Wardha ‑ 440 003, Maharashtra
Source of Support: None, Conflict of Interest: None
Percutaneous closure of the patent ductus arteriosus (PDA) in patients with interrupted inferior vena cava (IVC) poses a technical challenge. A 5-year-old girl with PDA and interrupted IVC is described in this report. The diagnosis of interrupted IVC and azygos continuation was made in the catheterization laboratory through infrarenal IVC angiogram. The procedure was shifted to IJV approach, and the device was delivered using a standard technique which completely occluded the PDA. Although echocardiographic assessment of systemic venous drainage is essential before any percutaneous intervention, cardiac catheterization is the most reliable method to define the systemic drainage. While IVC interruption can come as a surprise during therapeutic catheterization, one should be aware of and prepared with alternative strategies.
Keywords: Azygos vein, interrupted inferior vena cava, patent ductus arteriosus
|How to cite this article:|
Jawahirani AR, Fulwani M, Gadkari P, Gidhwani S. Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava. Indian Heart J Interv 2018;1:56-8
|How to cite this URL:|
Jawahirani AR, Fulwani M, Gadkari P, Gidhwani S. Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava. Indian Heart J Interv [serial online] 2018 [cited 2019 May 22];1:56-8. Available from: http://www.ihji.org/text.asp?2018/1/1/56/239779
| Introduction|| |
The first successful application of a transcatheter closure technique for patent ductus arteriosus (PDA) suitable for use in infants and children was performed in 1977. Transcatheter closure of PDA using various occluders and coils through femoral vein is a well-established therapeutic option. However, in patients with interrupted inferior vena cava (IVC), it is not feasible to close the PDA percutaneously using traditional methods. We present a 5-year-old girl with IVC interruption in whom percutaneous closure of PDA was successfully accomplished through the transjugular approach.
| Case Report|| |
A 5-year-old girl weighing 13.2kg was admitted to our hospital with a history of recurrent respiratory tract infections since birth. On clinical examination, she had a left ventricular (LV) apex and a continuous murmur in the left infraclavicular area. Her 12-lead electrocardiogram revealed sinus tachycardia with left atrial (LA) and LV enlargement. Chest X-ray posteroanterior (PA) view showed cardiothoracic ratio of 60%, prominent pulmonary conus, and plethoric lung fields. Transthoracic two-dimensional echocardiography confirmed moderate-sized conical PDA measuring 6mm at its narrowest point with evidence of LA and LV volume overload. A spectral Doppler revealed continuous flow across the PDA with peak systolic gradient of 90 mmHg and end-diastolic gradient of 38 mmHg. The right ventricular (RV) systolic pressure measured by tricuspid regurgitation velocity was 46 mmHg. With this data, it was decided to offer percutaneous closure of ductus to the patient to which parents agreed, and written informed consent was taken.
| Procedure|| |
After obtaining informed consent, the right femoral vein and artery were cannulated with 6F and 5F sheaths, respectively. During the right heart catheterization, course of the catheter suggested IVC interruption with azygos continuation into the right superior vena cava (SVC). It was confirmed with hand injection of contrast in the infrarenal portion of the IVC [Figure 1]. Aortogram was done in lateral view which showed moderate size PDA [Figure 2]. Since it was a case of interrupted IVC with PDA, it was decided to close the PDA through the right internal jugular vein (IJV), which was accessed with 6F sheath. A 6F Judkins right coronary catheter was advanced over straight tip 0.035’’ guide wire (Terumo Corporation, Tokyo, Japan) from right IJV to main PA through the RV. Through this catheter 0.035”, straight tip wire (Terumo Corporation, Tokyo, Japan) was passed across the PDA into descending aorta. Considering the angulations in the catheter course, we preferred to exchange the 0.035’’ wire with extra stiff Amplatz wire (Boston Scientific Corporation, Marlborough USA) for better support to position the delivery system across the PDA. An 8F delivery sheath was advanced and positioned in descending aorta over the Amplatz wire. Thus, the sheath had to take an almost 90° turn from the right atrium to PA and another 90° turn from PA to aorta. We did not encounter any difficulty while positioning the sheath but had some difficulty while advancing the device across the curves of the sheath at two 90° turns. Cocoon duct occluder (Vascular Innovations) 10/08mm size was screwed to the delivery cable and advanced through the delivery sheath [Figure 3] using the loader. The device was delivered using the standard technique. Lateral angiogram in the descending aorta revealed proper positioning of the device with mild residual flow through the device (“foaming”) [Figure 4]. Follow-up echocardiogram after 24h revealed trivial residual flow through the device.
|Figure 1: Fluoroscopic image in anteroposterior view showing interrupted inferior vena cava |
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|Figure 2: Fluoroscopic image of descending aortogram in lateral view showing moderate-sized PDA|
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|Figure 3: Fluoroscopic image of anteroposterior view showing multiple angulations of the delivery sheath|
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|Figure 4: Fluoroscopic image in lateral view showing patent ductus arteriosus device in situ|
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| Discussion|| |
Clinical presentation of patients with PDA is variable. It predominantly depends on the size of the PDA and the relationship between the systemic and pulmonary artery pressures and vascular resistance. Irrespective of the symptomatic status, clinically audible PDAs are closed surgically or through videoscopic-assisted minimally invasive technique or percutaneously using coils or devices.,,,,, With the advent of Amplatz duct occluder, almost all the PDAs beyond neonatal period and early infancy are closed with the transcatheter technique.
Owing to large vessel diameter and easy vascular access, percutaneous interventions in pediatric patients are conventionally done through femoral vein and artery. Interruption of the IVC with azygos continuation or drainage into the portal vein or hepatic venous plexus significantly adds technical challenges to percutaneous interventions performed through the femoral vein approach.,,, Some of the difficulties that can be encountered are kinking of catheters, failure to advance the delivery sheath, and kinking at Azygos-SVC junction and RV outflow tract. Akhtar et al. reported the closure of a PDA through a right IJV approach whereas Sivakumar and Francis have reported a retrograde approach from the aorta with a reversed device position, that is, the aortic disc facing the pulmonary artery and the tubular end facing the aorta. Koh et al. used the transarterial approach but with an ADO II device, which has discs on both sides. In our patient, we closed PDA with a technique similar to reported by Akhtar et al. The most important issue was to cross the sheath and device from two 90° curves across the RV and PDA which was done in this case with some technical difficulty of allaying the sheath over the wire and then device through the sheath.
| Conclusion|| |
PDA is not commonly associated with IVC interruption. Although echocardiographic assessment of systemic venous drainage is essential before any percutaneous intervention, cardiac catheterization is the most reliable method to define the systemic drainage. While IVC interruption can come as a surprise during therapeutic catheterization, one should be aware of and prepared with alternative strategies.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]