Abstract

Well-known complications of transcatheter shunt closure interventions are embolizations of devices. The initial procedure after embolization of a device is transcatheter interventions such as repositioning or retrieval with a sheath, bioptome or a snare. In some cases, surgical procedures may require and be privileged to reduce the harm to the patient. In this article, we report an eight-year-old boy who underwent surgical retrieval of Amplatzer™ Duct Occluder I device from the left pulmonary artery without cardiopulmonary bypass and discuss the safe retrieval techniques of commonly used devices.

Introduction

In recent years, interventional transcatheter device closure has become the most favorite treatment modality in congenital heart diseases. However, it can occasionally lead to catastrophic complications such as embolization. Although transcatheter retrieval is the first choice, surgical techniques may be inevitable in some cases. Herein, we report a surgical retrieval procedure of an embolized Amplatzer™ duct occluder (ADO) (Abbott Structural Heart, Plymouth, MN, USA) from the left pulmonary artery without cardiopulmonary bypass in the light of literature review.

Case Presentation

An eight-year-old male patient with a known patent ductus arteriosus (PDA) was admitted for percutaneous device closure. Echocardiography revealed a tubular PDA 6.4 mm in diameter and 21 mm in length, with moderate pulmonary hypertension and left ventricular dilatation. He underwent right heart catheterization which identified a 10-mm PDA.

The hemodynamic data showed a mean pulmonary artery pressure of 34 mmHg, with a mean aortic pressure of 55 mmHg. The Q p/Qs ratio was 2.89 and Rp/Rs ratio was 0.09. Balloon occlusion showed a drop in pulmonary pressures to half of systemic and a 12¥10 mm ADO I device (Abbott Structural Heart, Plymouth, MN, USA) was positioned with success. Within few hours of deployment, control telecardiogram and echocardiography revealed that the device was embolized into the left pulmonary artery (Figure 1). The initial plan was to retrieve the device angiographically with percutaneous technique. Several attempts with 5Fr Judkins and 5Fr Multipurpose catheters failed.

The patient was immediately transferred to the operating room. Median sternotomy was performed.

He was hemodynamically stable. Aorta, pulmonary artery, and PDA were dissected. The device was fell in the left pulmonary artery. The distal end was controlled with snares and occluded, and the proximal part of left pulmonary artery was crossclamped and an arteriotomy over the device was performed. We removed the device successfully without any complication. The PDA was ligated with the Ethibond® suture and transfixed. The pulmonary artery was primarily repaired using 5-0 prolene sutures. After the operation, the patient was transferred to cardiac intensive care unit, extubated within few hours, and discharged home on the third postoperative day with full recovery. Follow-up echocardiogram showed no flow across the ductus arteriosus, no residual defect, and no peripheral pulmonary arterial stenosis. A written informed consent was obtained from the parents and/or legal guardians of the patient.

Discussion

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).

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.