Inadvertent stenting of patent ductus arteriosus with Amplatzer Vascular Plug

Transvenous embolization of moderate to large patent ductus arteriosus in dogs using the Amplatzer vascular plug II

BACKGROUND

Catheter-based occlusion of patent ductus arteriosus (PDA) can be performed using different devices. Transvenous embolization using the Amplatzer vascular plug II (AVP-II) has been studied in humans, but it has not been described in dogs.

OBJECTIVE

Evaluate the feasibility and success of transvenous embolization of PDA using the AVP-II in dogs.

ANIMALS

Nineteen client-owned dogs with left-to-right shunting PDA, with minimal ductal diameter >2.5 mm.

METHODS

Prospective observational study using AVP-II with transvenous access for PDA closure in dogs.

RESULTS

Angiography showed a conical ductus with a long (n = 17) or short (n = 2) ampulla. The minimal diameter of the duct was 4.34 ± 1.11 mm, and the maximal diameter of the ampulla was 13.18 ± 3.47 mm. Technical success was achieved in 18 of the 19 (94.7%) patients after the first intervention and in all 19 (100%) patients after the second intervention. Postrelease angiography documented complete occlusion of the PDA in 10 of 19 (52.6%) dogs. Mild flow acceleration or stenosis of the left pulmonary artery was found in 6 and 1 of the 17 analyzed cases, respectively, by Doppler examination. The closure rate 24 hours after intervention was 94.7% (18/19). The remaining dog had a moderate residual shunt, and delayed complete closure after 3 months led to a 100% closure rate.

CONCLUSION AND CLINICAL IMPORTANCE

The AVP-II is a safe and effective device for transvenous embolization in dogs with moderate to large PDA.

Percutaneous closure of a moderate to large tubular or elongated patent ductus arteriosus in children younger than 3 years: is the ADO II appropriate?

Protrusion of the Amplatzer duct occluder (ADO) II device into the aortic isthmus or the pulmonary artery causing obstruction and residual flow has been reported, but the same has not been widely studied in small children with a patent ductus arteriosus (PDA) anatomy not considered suitable for closure with the ADO I device. This study aimed to report the safety and efficacy of the ADO II device in children younger than 3 years with a tubular or elongated PDA and to analyze the possible reasons for residual flow in children with such a PDA. In this study, 17 children younger than 3 years (mean age, 10.3 ± 7 months; mean weight, 6 ± 3.6 kg) underwent attempted closure of a tubular or elongated PDA (mean diameter at the narrowest point, 4.1 ± 1.1 mm) with the ADO II device between July 2010 and July 2012. Of the 17 patients, 16 (2 boys and 14 girls) completed the follow-up evaluation. A complete echocardiographic evaluation was performed on all the patients before PDA closure and at the follow-up visit, and the results were compared with those of previous published studies. Of the 16 patients, the 15 who completed the follow-up evaluation had successful device closure (1 device embolization). Residual flow was present in six patients immediately after deployment, which was reduced to three patients at the last follow-up visit. Five of nine patients closed with a 6-mm-long device had residual flow compared with only one of seven patients closed with a 4-mm-long device. After device closure, significant elevations of the left and right pulmonary artery velocities occurred in three and two patients, respectively; in 12 patients, descending thoracic aortic (DTA) velocities increased mildly. There was trend toward a fall in the elevated pressures at the last follow-up visit, although one patient had an elevation in right pulmonary artery velocity at last the follow-up echocardiogram compared with the echocardiogram immediately after closure. Hence, in children younger than 3 years with or without pulmonary arterial hypertension, closure of a PDA not amenable to closure with the ADO I device is feasible using the ADO II device, with an increased incidence of clinically nonsignificant complications. Selection of device dimensions according to the manufacturer's recommendation may not be the optimal strategy.

Patent ductus arteriosus closure using the Amplatzer® vascular plug II for all anatomic variants

OBJECTIVES

To evaluate the safety and efficacy of the Amplatzer® Vascular Plug II (AVPII) for closure of the patent ductus arteriosus (PDA).

BACKGROUND

The PDA has significant anatomic variation. No device has proven applicable to all PDAs. Previous case reports and small series have documented limited use of the AVPII for some PDA types. We describe the largest and most diverse experience using the AVPII.

METHODS

A retrospective analysis of patients undergoing percutaneous PDA closure between 01/01/2009 and 05/01/2012 was performed. The PDA was characterized, measured, and the device chosen was listed. Deployment technique, complications and procedural results were recorded.

RESULTS

Sixty-seven procedures were performed. The AVPII was utilized for 43 (64.2%), 15 (20.9%) had coils, 7 (10.4%) had the AGA duct occluder, and 3 (4.5%) were referred for surgery. The AVPII was placed in infants as young as 2 months and 4.2 kg. AVPII size ranged from 4 to 10 mm. All PDA types were closed. Retrograde and antegrade deployments were performed, using the outer disc as a "retention skirt" to secure the device and improve occlusion. Three patients were up-sized prior to release. All deployments were successful; 89% "in-lab" and 100% closure on postprocedural echocardiogram. There were no complications.

CONCLUSIONS

We report the largest experience with the AVPII for PDA closure. The device was used in all morphologic types and small patients. It is low profile, easily repositioned, and had excellent results without complications. We contend that this is the most versatile device currently available.

Transcatheter interruption of large residual flow after device closure of "Type A" patent ductus arteriosus

We report a case of 3-year-old girl who had persistence of large residual flow following transcatheter closure of a 6 mm ‘Type A’ patent ductus arteriosus using a 12 × 10 mm duct occluder. Angiography revealed a large left-to-right shunt coursing through and exiting around the implanted device. Near total abolition of the residual shunt was achieved by initial implantation of an embolization coil within the duct occluder and subsequently an Amplatzer duct occluder (ADO II) adjacent to the duct occluder. This challenging case describes an additional technique of abolishing a large residual flow in and around a Nitinol duct occluder device.

Transcatheter closure of patent ductus arteriosus: Evaluating the effect of the learning curve on the outcome

Background and Objectives:

Initial experience with transcatheter closure of patent ductus arteriosus (PDA) using detachable coils and Amplatzer duct occluder devices is reported. We evaluated the outcome, complications, and influence of the learning curve, and also assessed the need of surgical backup for such interventional procedures.

Methods:

From January 2000 to December 2004, 121 patients underwent transcatheter closure of PDA. Aortic angiogram was performed to evaluate the size, position, and shape of the duct for appropriately choosing the occluder device type and size. A second aortic angiogram was performed 10 minutes after device deployment. Echocardiography was repeated at intervals of 24 hours, then at 1, 3, and 6 months after the procedure to assess complications. Stepwise multiple regression analysis was used to assess the role of experience in improving the outcome of the procedure.

Results:

Of 121 cases, four patients had pulmonary artery embolization of the occluder device which was successfully retrieved in the catheterization laboratory, while two others had embolization that required surgical intervention. Four patients had temporary residual leak, nine had protrusion of the device into the aorta without significant Doppler pressure gradient or hemolysis on follow-up, and five had partial hemodynamically insignificant obstruction to the left pulmonary artery. Statistical analysis showed that the effect of the learning curve and experience was responsible for 93% improvement in the procedural outcome over the five-year study period.

Conclusion:

Transcatheter occlusion of PDA is safe and effective alternative to surgery. Complications occurred in those with unfavorable duct anatomy and with the use of multiple coils. Surgical backup was important for such interventional procedures. Experience played a major role in the proper choice of device type and size which greatly influenced the outcome of the procedure.

Extended applications of the Amplatzer vascular plug IV in infants

OBJECTIVE

A variety of devices are available for transcatheter closure of unwanted shunts. We describe our experience with the use of the Amplatzer vascular plug IV in a consecutive series of infants.

METHODS

A total of eight consecutive infants - all born preterm at gestational ages ranging from 24 to 35 weeks - undergoing transcatheter closure of unwanted shunts - persistently patent arterial duct in five patients, an aorta to right atrium fistula in one, multiple aortopulmonary collateral vessels in one, and an azygos vein to left atrium connection in one - are described. Their age, from birth, ranged between 3 and 11 months, and weight between 2.6 and 11.3 kilograms. All devices were delivered using percutaneous arterial or venous vascular access via a large lumen (0.038 inch) 4-French delivery catheter.

RESULTS

All lesions could be successfully occluded using one or more devices. Device diameters ranged between 4 and 8 millimetres, and exceeded the minimum diameter of the target vessel by 1 to 2 millimetres. Successful occlusion was confirmed either directly at angiography or on follow-up echocardiography. Of the infants who were mechanically ventilated prior to the procedure, three could be successfully weaned following closure of the shunt. There were no procedure-related complications.

CONCLUSIONS

The new vascular plug IV is cheap and efficacious in closing a variety of shunts in young infants, and warrants further extended clinical application.

Minimally invasive per-catheter occlusion and dilation procedures for congenital cardiovascular abnormalities in dogs

With ever-increasing sophistication of veterinary cardiology, minimally invasive per-catheter occlusion and dilation procedures for the treatment of various congenital cardiovascular abnormalities in dogs have become not only available, but mainstream. Much new information about minimally invasive per-catheter patent ductus arteriosus occlusion has been published and presented during the past few years. Consequently, patent ductus arteriosus occlusion is the primary focus of this article. Occlusion of other less common congenital cardiac defects is also briefly reviewed. Balloon dilation of pulmonic stenosis, as well as other congenital obstructive cardiovascular abnormalities is discussed in the latter part of the article.

Transcatheter closure of the patent ductus arteriosus using the new Amplatzer duct occluder: initial clinical applications in children

BACKGROUND

In spite of recent advances in transcatheter management, the occlusion of certain anatomic types of patent ductus arteriosus (PDA), especially in infants and small children, remains a challenge. The aim of the study was to report initial human experience with transcatheter closure of PDA in 25 patients using the new Amplatzer duct occluder (ADO II) (AGA Medical, Golden Valley, MN).

METHODS

The median age of the patients was 3.2 years (range 0.1-5 years), and the median weight was 10.5 kg (range 3-18 kg). The device used is a modified ADO II made of fabric-free fine Nitinol wire net into 2 very-low-profile disks with an articulated connecting waist. Both disks are 6 mm larger than the diameter of the connecting waist. Connecting waist diameters range from 3 to 6 mm.

RESULTS

The mean PDA diameter was 3.6+/-1.3 mm (range 0.6-5 mm). The mean device diameter (waist diameter) was 4.3+/-1.4 mm (range 3-6 mm). Complete echocardiographic closure of the ductus at 1-month follow-up was observed in 24 (96%) of 25 patients. Immediately after the procedure, there was a mild left pulmonary stenosis (Doppler gradient of 15 mm Hg) in 2 of 25 patients. No other complications were observed.

CONCLUSIONS

The ADO II is a promising addition to our armamentarium for PDA closure. Further studies are required to document its efficacy, safety, and long-term results.

Comparison and results of transcatheter closure of patent ductus arteriosus using the swivel-disk device versus plug occluder in children

The transcatheter closure of certain types of patent ductus arteriosus (PDA) remains a challenge. The investigators report initial clinical experience with 25 patients who underwent PDA occlusion with the use of a swivel-disk device (SDD) or a plug occluder (PO). The patients were divided into 2 groups: in the SDD group, 12 patients aged 1 to 2 years with type A PDA underwent attempted closure using the SDD, a modified Amplatzer duct occluder with a very low profile retention disk that can adapt itself at different PDA insertion angles. The mean PDA diameter was 4.8 +/- 1.5 mm (range 3.8 to 8). In the PO group, 13 patients aged 0.5 to 3 years with type C, D, or E PDA underwent attempted occlusion with the PO, a tubular occluder made of Nitinol wire mesh. The mean PDA diameter was 4.2 +/- 3.5 mm (range 1.2 to 9). The 2 occluders are filled with Dacron patches. The mean device diameters were 6.5 +/- 1.2 and 6.8 +/- 2.2 mm (range 4 to 11) in the SDD and PO groups, respectively. Complete angiographic closure was seen in 24 of 25 patients. The deployment of 4 5-PDA5 coils abolished a residual shunt associated with hemolysis in a 5-month-old patient with a large type C PDA after the implantation of an 11-mm PO. No other complications were observed. In conclusion, the SDD and the PO are promising additions to the armamentarium for PDA closure.