Pulmoner artere embolize olan Amplatzer duktus kapama II cihazının “Goose Neck” kement ile çıkarılması

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Introduction
Percutaneous transcatheter closure has been used
extensively as a safe and effective alternative treatment modality to surgical closure in patients with patent ductus arteriosus (PDA) over the past 30 years
(1). The Amplatzer® Duct Occluder II (ADO II) device
made from nitinol wire mesh has a widespread use in
the era of percutaneous transcatheter closure of PDA.
Although the complications are rare, device embolization requiring transcatheter or occasionally surgical retrieval may occur. Embolization usually occurs
in the early hours after implantation and trends to
the branches of pulmonary arteries (2). In this report
we present a case of embolization of ADO II device to
the pulmonary artery and retrieval of it with “Goose
Neck” snare successfully.
Case Report
A 22-year-old male was taken into the catheterization laboratory to perform percutaneous closure of
PDA by using the retrograde guide-wire technique.
The procedure was initated by puncturing of right femoral artery under local anesthesia. The size of PDA
was measured 6 mm by descending aortagraphy and
it was decided to use a 6x6 mm ADO II device. A
0.0035” glide wire was passed through the aorta into
the pulmonary artery with the guidance of 6 F right
Amplatz II diagnostic catheter. Subsequently, glide
wire was exchanged with an extra stiff wire. The delivery system was advanced over the extra stiff wire into
the pulmonary artery. The distal disc of ADO II device (AGA Medical Corp., Golden Valley, Minnesota,
USA) was opened in the pulmonary artery, and then,
the system was withdrawn slowly and the proximal
disc opened in the aorta. Subsequently, the device
was released after being sure that device was placed
correctly. However, a severe residual shunt was present on control descending aortagraphy recorded 10
minutes after implantation (Figures 1A and 1B). Then
*Department of Cardiology, Gulhane Military Medical Faculty
Reprint request: Dr. Murat Çelik, Department of Cardiology, Gulhane
Military Medical Faculty, Etlik-06018, Ankara
E-mail: drcelik00@hotmail.com
Date submitted: April 13, 2010 • Date accepted: July 15, 2010
SUMMARY
Percutaneous transcatheter closure of patent ductus arteriosus is a wellestablished procedure. Although it has been known as a safe treatment
strategy, some complications have been reported. Embolization of the device, especially to the pulmonary artery, is one of these complications. In
this report, we present a patient in whom an Amplatzer® duct occluder
(ADO) II device embolized to the pulmonary artery and it was retrieved by
using “Goose Neck” snare. We would like to notice the great importance of
accurate preprocedural measurement of ductus arteriosus diameter during
percutaneous transcatheter closure which seems to be a simple procedure.
Key words: Amplatzer duct occluder, “Goose Neck” snare, patent ductus
arteriosus, percutaneous transcatheter closure
ÖZET
Pulmoner artere embolize olan Amplatzer duktus kapama II cihazının
“Goose Neck” kement ile çıkarılması
Patent duktus arteriyozusun perkütan transkateter yol ile kapanması olduk-
ça iyi bilinen bir yöntemdir. Oldukça güvenli bir tedavi olarak bilinmesine
karşın, işlemle ilgili bazı komplikasyonlar bildirilmiştir. Cihazın özellikle pulmoner artere embolizasyonu bu komplikasyonlardan birisidir. Bu olgu sunumunda, Amplatzer® kapama II cihazının (ADO) pulmoner artere embolize olduğu bir hastayı ve embolize olan cihazın “Goose Neck” kement ile geri
çıkarılmasını sunduk. Kolay gibi gözüken perkütan transkateter kapama işleminde, duktus arteriyozus çapının işlem öncesinde doğru ölçülmesinin önemini vurgulamak istedik.
Anahtar kelimeler: Amplatzer kapama cihazı, “Goose Neck” kement,
patent duktus arteriyozus, perkütan transkateter yolla kapamaVolume 52 • Issue 4 Embolization of ADO II device • 277
we decided to retrieve the device by using a gooseneck snare and replace with a larger ADO II device.
The device had embolized to the branches of pulmonary artery as just as touching the device with snare. The device was seen in the bifurcation among two
pulmonary artery branches under fluoroscopic images and a partial blocking of pulmonary arterial blood flow was observed on pulmonary angiography
(Figure 2). A gooseneck snare was advanced to the
pulmonary artery via the right femoral vein. After several unsuccessful attempts to reach to the device because of several bifurcative complex branches of pulmonary artery, the device was captured from its screw
by using “Goose Neck” snare and device was retrieved successfully (Figure 3). A larger size of ADO I device (8 mm aortic disc and 6 mm on pulmonary side,
device length 7 mm) was implanted to the patient
by using antegrade guide-wire technique. There was
Figure 1. Cinegraphy demonstrated that ADO II device was placed correctly with retrograde guide-wire technique (A) and severe residual shunt
was seen on descending aortagraphy after device release (B). White arrows show the ADO II device and arrow heads point out severe residual
shunt after placement
Figure 2. Cinegraphy showed that ADO II device embolized into the
distal branch of pulmonary artery and blocked partially the blood flow
of pulmonary artery
Figure 3. It was seen that the ADO II device was catched from its
screw by using gooseneck snare and drawn back to the femoral
sheat in right femoral vein278 • December 2010 • Gulhane Med J İyisoy et al.
no abnormality on control descending aortagraphy
in the next morning (Figures 4A and 4B), and then
the patient was discharged in a very good condition.
Discussion
PDA is one of the most common congenital abnormalities (3). Since the first successful surgical closure by Gross and Hubbard (4), and the first transcatheter occlusion by Porstmann (5), the treatment modalities for PDA have continued to evolve. Various closure devices, occluders and coils have been used to
occlude the PDA. However, they had some limitations such as high incidence rate of residual shunting,
complex delivery systems and large delivery sheaths
(6). ADO devices, which can be delivered through a
relatively small delivery system, were introduced to
handle these limitations. ADO I was introduced in
1999 and ADO II in 2009.
It has been shown that the use of the ADO was safe
and the success rate of procedure was relatively higher
than those of other devices. In their study of 205 patients with PDA, Bilkis et al. reported that closure of PDA
using ADO I was successful in all patients and complication rate was 3% (2). Also, Faella and Hijazi reported
that the occlusion rate was up to 100% after one year’s
follow up, and complication rate was 2% in their international registry of transcatheter closure with ADO (7).
Complications including death, device embolization (to the pulmonary artery or aorta), partial obstruction of the left pulmonary artery, aortic narrowing, arrhythmias, transient asystole, significant bleeding, loss of femoral pulse, pseudo-aneurysm formation and groin hematomas during this procedure have been reported (7,8). However, some large series reported no such complications (3). The embolization of PDA closure device is a frequent complication of this procedure and usually occurs into the pulmonary artery. It was mainly thought to be associated with undersized devices (7). A descending aortagram in the lateral projection was recorded to define the morphology and size of the duct, and this
might be the reason of undersizing of PDA in our
case. However, a biplane anteroposterior and lateral
descending aortagram could be performed to evaluate the correct size, position and shape of the ductus.
All types of PDAs measuring 2.5 mm to 5.5 mm in
diameter can be occluded with ADO II device. The
“window-type” PDA in the Krichenko classification
(9) and PDAs measuring >12 mm in length and >5.5
mm in diameter on angiography are not suitable for
closure with ADO II. The embolization of ADO II device occurred into the pulmonary artery probably
from undersizing and was retrieved successfully with
snare by catching from its screw in our case. But, retrieval of the device was not easy. Because finding the
correct distal branch of pulmonary artery, in which
ADO II device was embolized, and catching the device from its screw were so difficult.
In conclusion, this case has been presented to emphasize the great importance of preprocedural duct
measurement during percutaneous transcatheter closure of PDA, which seems to be a simple procedure.