Transcatheter PDA closure was first applied in
1967 and the procedure became more practical. There
have been many dramatic improvements and, over the
last two decades, transcatheter approaches has become
the considerable.[
1]
Anatomical varieties, calcification and aneurysm
formation, left ventricular dysfunction and pulmonary
hypertension may complicate transcatheter closure of
PDA.[2]
Currently, in most age groups, except premature
infants, transcatheter therapy for persistent flow
through the arterial duct is accepted as a well-established alternative. The design of occluder devices has been
improved regarding the occlusion rate, stability, and
smaller sizes of delivery systems. The initial ADO
can accomplish high rates of occlusion with minimum
complications in different sizes and morphology of
ducts and age groups.[3]
There are several factors which affect the
performance of transcatheter device closure of PDA
such as vascular accessibility, anatomical structure of
the ductus, and selecting optimal device. The ADO II
devices (Abbott Structural Heart, Plymouth, MN,
USA) are the proper for retrograde aortic approach.
Small-sized ducts are convenient for coils, and
occluders are usually used for larger ones.[4]
Severe complications such as embolization,
infection, hemolysis, protrusion into aorta or
pulmonary artery causing obstruction or narrowing,
spontaneous recanalization and post-procedure left
ventricular systolic dysfunction have been defined
after percutaneous techniques.[5,6]
The role of all transcatheter closure procedures
of intracardiac and extracardiac shunts has gained importance in recent years as PDA closure. These
procedures eliminate the need for sternotomy and
cardiopulmonary bypass and shortens the length of
hospital stay.[7] Although percutaneous techniques
become popular due to less mortality and morbidity
rates and early discharge from hospital, they are not
free of complications. Device embolizations in different
sites of circulatory system may cause life-threatening
damages. In the literature, device embolization rates
were 4% in 1991, 20% in 1996, and 0.55% in 2005.[8,9]
New generation devices significantly decreased serious
complications.[8,9] However, embolized devices which
require urgent surgical management are still reported
and majority of these are case reports.[10,11]
In the literature, from 72 embolization cases
between years 2000 and 2020, 40 of them were atrial
septal defects, 17 were PDA, nine were ventricular
septal defects, three were patent foramen ovale with
neurological symptoms and signs, one was mitral
paravalvular leak, one was coronary-cameral fistula,
and one was ascending aorta pseudoaneurysm. The
most frequently embolization site of the device
was pulmonary artery, similar to our case. In the
relevant literature, device removal or repositioning
was achieved mostly through the percutaneous
route. A total of 49 of 71 cases were rescued via
transcatheter techniques. Twenty-three patients
underwent surgical procedure. All embolized
devices were successfully retrieved both surgically
and angiographically (Table 1).
Table 1: Review of the literature on surgical retrieval of embolized devices
In hemodynamically stable cases, the first choice is
to attempt percutaneous rescue methods. The retrieval
of an embolized device from the pulmonary artery
by snaring technique has been described and there
are various reports regarding the successful retrieval
devices either by surgery, a percutaneous method using
various snares or bioptomes, or by a sheath in the
sheath technique.[12,13]
After device embolization, the main goal is to
localize the embolized device into a harmless position.
Operators using transcatheter occluder devices should
be familiar with performing percutaneous retrieval
techniques. However, in life-threatening cases,
it should not be late for recognition and surgical
intervention. It is also important to consider late
embolization of devices and close follow-up with
X-ray and control echocardiograms to realize earlier.
The literature strongly suggests that these devices
should be only inserted in facilities, where back-up of pediatric cardiovascular surgical cover, operating
room, and blood product preparations are immediately
available. Although the embolizations seem to be
rare, the results may be destructive such as extremity
loss, mortality or, at least in the best-case scenario,
recurrent surgical and/or endovascular interventions
may be required.[14]
In conclusion, although transcatheter closure
is applicable and advantageous even in the lowest
weight infants, there are absolutely many serious
catheterization-related risks, as the patient size becomes
smaller. Further improvements would advance the
safety and utility of transcatheter procedures.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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