Transcatheter occlusion of an intrahepatic venovenous fistula after modified Fontan circulation by implantation of an Amplatzer atrial septal occluder

Transcatheter occlusion of a hepatic vein-to-left atrium fistula: Should we close venovenous collateral vessels following Fontan operation?

Right-to-left shunt due to abnormal systemic venous drainage to the left heart is among the causes of hypoxemia following Fontan operation. There are conflicting data regarding the closure of the venovenous collaterals (VVCs) post-Fontan, showing decreased survival in older patients. In a child with visceral heterotaxy, we describe a rare fistula draining a right-sided hepatic vein into hepatic venous plexus and a right-sided pulmonary venous atrium. The patient presented with severe hypoxemia post-Fontan and underwent fistula occlusion with AMPLATZER™ Vascular Plug II, successfully improving hemodynamic status with resolution of the hypoxemia. Younger patients with cyanosis due to VVCs may benefit from percutaneous occlusion post-Fontan.

Novel use of covered stents to treat profound cyanosis in a hepatic vein exclusion Fontan

Fontan completion in patients with complex cardiac anatomy, and specifically heterotaxy syndrome, can present unique physiologic considerations. For example, existing venous connections may be “unmasked” after a cavopulmonary anastomosis operation. We present the case of a child with heterotaxy, dextrocardia, single-ventricle physiology, and anomalous hepatic venous drainage that resulted in profound shunting and cyanosis. We addressed the problem utilizing a novel strategy with a “fenestrated” covered stent.

Major Intrahepatic Veno-Venous Fistula after Fontan Operation Treated by Transcatheter Implantation of Amplatzer Septal Occluder through Internal Jugular Vein

Six months after undergoing a Fontan operation, a 7-year-old boy with right atrial isomerism and a single functional ventricle was admitted to our emergency department with cyanosis. Emergency cardiac catheterization revealed a large veno-venous fistula that began in a left hepatic vein, connected to the left accessory hepatic veins, and drained into the common atrium, resulting in desaturation. The fistula was occluded proximally with an Amplatzer septal occluder, with satisfying results; the patient's systemic arterial saturation decreased during his hospital stay. Three weeks after the first intervention, a second procedure was performed to retrieve the first device and to close the fistula distally. Multiple attempts with different types of gooseneck snares and a bioptome catheter failed to retrieve the first device, so a telescopic method was used to re-screw it. Using a Mullins long sheath and delivery sheath, the delivery cable was manipulated to fit into the slot of the end screw, and the cable was rotated gently in a clockwise direction to re-screw the device. Then, another Amplatzer septal occluder was placed at the distal end of the fistula. In conclusion, distal transcatheter occlusion of intrahepatic veno-venous fistulas might lead to better clinical outcomes in selected patients. Amplatzer septal occluder device can be retrieve without any complication within three weeks.

Percutaneous transcatheter closure of a large systemic to pulmonary venous fistulae in an adult patient after extracardiac fontan

Vascular fistulae are frequent complications in patients who have undergone a Fontan operation for palliation of single ventricle physiology. Fistulae involving the pulmonary vasculature may result in progressive hypoxemia, pulmonary hemorrhage, and clinical symptoms. These are commonly managed by percutaneous transcatheter embolization utilizing coils, and more recently, vascular plugs and septal occluders. We present a clinical case of an adult patient who underwent an extracardiac Fontan procedure in childhood for univentricular physiology and presented with symptoms of systemic desaturation 10 years after his surgery. The patient was found to have a large fistula from the inferior vena cava to the right inferior pulmonary vein. The fistula was attempted to be closed with a 12 mm Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN). Angiography showed continued flow across the fistula, which was then successfully occluded with an 18 mm Amplatzer "Cribriform" Septal Occluder (St. Jude Medical, St. Paul, MN). The patient experienced immediate improvement in his systemic saturation, and demonstrates continued resolution of his symptomatic hypoxia on follow-up. This case illustrates an uncommon systemic to pulmonary vein fistula after Fontan, and a unique, successful embolization with two septal occluders, resulting in sustained symptomatic improvement.

Percutaneous device occlusion of hepatocardiac venous collateral via left transhepatic access in a patient with heterotaxy syndrome following Fontan procedure

Venovenous collateral vessels are a common cause for desaturation in patients who have undergone a Fontan procedure. We describe a patient with heterotaxy syndrome (leftward pointing apex) and complex single ventricle with Fontan physiology that was desaturated due to a hepatocardiac vein. The vessel was entered via a left transhepatic access and was successfully occluded using an Amplatzer Vascular Plug.

Interventional occlusion of a thrombosed aortic conduit

We report the first known closure of an aortic conduit with the Amplatzer plug device. The device was used in the case of a 20-year-old male who presented with an aortic conduit that had thrombosed and had formed a pseudo-aneurysm. A 14-mm plug and a 16-mm plug were used to close off the proximal portion of the conduit in preparation for surgery. The successful use of the device minimized the risk and the extent of the subsequent surgery.

Enlarged left vitelline vein remnant as a cause of cyanosis after the Fontan procedure: resolution with an Amplatzer vascular plug

A 6-year-old girl with heterotaxy and a functional single ventricle had persistent cyanosis 4 years after a fenestrated Fontan procedure. Cardiac catheterization revealed a large venous fistula from a left-sided hepatic vein to the coronary sinus, resulting in desaturation. The anomalous vein was occluded with an Amplatzer vascular plug.

Percutaneous Treatment of Aberrant Right Subclavian Artery Aneurysm with Use of the Amplatzer Septal Occluder

Aberrant right subclavian artery (ARSA) aneurysms are rare but carry a high risk of rupture and require early elective treatment. The present report describes a 60-year-old man with an asymptomatic ARSA aneurysm for whom surgical treatment would have been associated with a high degree of risk. The ARSA aneurysm was occluded with use of Amplatzer septal occluders, which avoided high-risk surgery and preserved antegrade flow into the left common carotid, subclavian, and vertebral arteries and perfusion of the right upper extremity through an induced right subclavian steal. The eventual need for bypass surgery for perfusion of the right upper extremity was assessed after the procedure.