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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 20-22  

A challenging case of patent ductus arteriosus device closure in an adult with unconventional views and catheters


Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India

Date of Web Publication10-May-2018

Correspondence Address:
Dr. Deep Chandh Raja
Department of Cardiology, Sanjay Gandhi PGIMS, Raibareli Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_36_17

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   Abstract 


Abnormally oriented patent ductus arteriosus is expected in adults, which can lead to difficulties while attempting a device closure. Alternate angiographic views like the “right anterior oblique view,” “retrograde approach” and in rare cases, as elicited in the following case scenario, special catheters like the “Tiger® catheter” can aid in crossing the lesion and completion of the procedure successfully.

Keywords: Patent ductus arteriosus, retrograde approach, right anterior oblique view, Tiger® catheter


How to cite this article:
Garg N, Raja DC, Khanna R, Kumar S. A challenging case of patent ductus arteriosus device closure in an adult with unconventional views and catheters. Heart Views 2018;19:20-2

How to cite this URL:
Garg N, Raja DC, Khanna R, Kumar S. A challenging case of patent ductus arteriosus device closure in an adult with unconventional views and catheters. Heart Views [serial online] 2018 [cited 2022 Jan 17];19:20-2. Available from: https://www.heartviews.org/text.asp?2018/19/1/20/232156




   Introduction Top


Transcatheter closure of patent ductus arteriosus is the standard of care. However, patent ductus arteriosus in adults pose unique challenges. It may be difficult to visualize the entire length of the patent ductus arteriosus in the left lateral view as the patent ductus arteriosus may have an end-on orientation. In addition, it may not be always possible to cross the patent ductus arteriosus with a routine antegrade technique. In the following case description of a patent ductus arteriosus device closure in an adult, we find the utility of the “right anterior oblique 40° view” and the “Tiger ® catheter” in solving the various difficulties encountered during the procedure.


   Case Presentation Top


A 40-year-old female with features of the left ventricle volume overload was diagnosed to have a 6 mm patent ductus arteriosus by echocardiography. The patient was taken up for device closure after confirmation of mild elevated pulmonary artery pressures (mean 25 mmHg). The patent ductus arteriosus was foreshortened because of the “end-on” orientation in the left lateral 90° view [Figure 1]a. However, the right anterior oblique 40° view [Figure 1]b was helpful in separating the patent ductus arteriosus from the aortic shadow and thus, proper profiling of the patent ductus arteriosus. The patent ductus arteriosus was found to be horizontally oriented with an ampulla measuring 5.2 mm and the narrowest point on the pulmonary end measured 3.1 mm. The length of the patent ductus arteriosus segment was 7 mm. This was a type A (Krichenko classification) patent ductus arteriosus.
Figure 1: (a) Left lateral 90° view showing the “end-on” orientation and improper profiling of the patent ductus arteriosus. (b) Right anterior oblique 40° view showing the separation of the patent ductus arteriosus from the aortic shadow. (c) Right anterior oblique 40° view showing the Tiger® catheter hooking the aortic end of patent ductus arteriosus. (d) Anteroposterior view showing the exchange length Terumo wire which was snared from the venous side. (e and f) Right anterior oblique 40° view in which a 6 mm × 8 mm Cocoon duct occluder was placed antegradely and released

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The initial attempts to cross from the pulmonary end of the patent ductus arteriosus with an antegradely placed multipurpose catheter failed. We opted for the retrograde approach where in the right anterior oblique 40° view, following failed attempts with a Judkins right 3.5, a multipurpose catheter, left internal mammary catheter, Amplatz left and right catheters, we used an Optitorque TIG catheter; Tiger ® catheter (Terumo, Japan) to hook the aortic end of patent ductus arteriosus [Figure 1]c. In the right anterior oblique 40° view, we pulled the Tiger ® catheter caudally starting from the aortic arch. The Tiger ® catheter quickly jumped into the ostium of the patent ductus arteriosus.

The selective injections confirmed the contrast opacification of the pulmonary arteries and thus, successful engagement of the patent ductus arteriosus. A 0.025” Super stiff Amplatz ® wire was advanced and the Tiger ® catheter was advanced into the pulmonary artery. In the anteroposterior view, 0.035” exchange length Terumo wire was snared from the venous side with a Gooseneck snare [Figure 1]d. A 6 mm × 8 mm Cocoon Duct Occluder (Vascular Innovations Co., Thailand) was placed antegradely; however, the position of the device was unconvincing in the left lateral 90° view. There seemed to be a significant protrusion of the device into the aorta. The right anterior oblique 40° view [Figure 1]e and [Figure 1]f revealed a more assured position of the device and the device was released in the same view.


   Discussion Top


This case highlights three important aspects – the abnormal orientation of patent ductus arteriosus in adults, the usefulness of the right anterior oblique 40° view, and the unique utility of the Tiger ® catheter.

In adults, as in this patient in her fourth decade, the orientation of the patent ductus arteriosus is not the same as in patients presenting in the pediatric age group. Aortic enlargement secondary to hypertension, pulmonary artery enlargement due to the hyperkinetic circulation, and the distorted anatomy of the patent ductus arteriosus per se due to persistent flow may contribute to unique difficulties in these patients taken up for device closure.

Conventionally, left lateral view is adopted for angiographic visualization of the patent ductus arteriosus. However, due to a variety of anatomical variations, it may be difficult to properly visualize and deploy the device in the left lateral view. In a series of 117 patients by Garg et al.,[1] an abnormally oriented and foreshortened patent ductus arteriosus in the form of an “end-on patent ductus arteriosus” was noted in 20.5% of the patients in the left lateral view. The right anterior oblique view helps in separating the patent ductus arteriosus from the aortic shadow.[2] However, if the duct is fully profiled in the left lateral view, the right anterior oblique view may not be of any help and can be avoided.

The series by Garg et al.[1] also highlights the uniqueness of the right anterior oblique view in aiding crossing of the “end-on patent ductus arteriosus.” The right anterior oblique view also aided in proper deployment of the patent ductus arteriosus device with great confidence in all such patients as it can clearly show the correct position of the aortic disc and the device position can be correctly identified before release. In this particular case, the right anterior oblique view helped immensely in profiling the patent ductus arteriosus, in retrograde crossing of the patent ductus arteriosus as well as in successful deployment of the device.

This case highlights the versatility of the Tiger ® catheter. The Optitorque Radial Tiger ® diagnostic catheters manufactured by the Terumo ® Corporation (Japan) are unique catheters which are popularly used in hooking of both right and left coronary arteries from the radial access. The Tiger ® catheter has one end hole and one side hole and is uniquely designed for a coaxial engagement of the ostium. We found this catheter useful in “hooking” of a horizontally oriented patent ductus arteriosus from the aortic end.


   Conclusion Top


In an abnormally oriented patent ductus arteriosus, which is to be anticipated in adults, a Tiger ® catheter, the right anterior oblique 40° view and a retrograde approach has helped in successful deployment of the device. Adults with patent ductus arteriosus, therefore, warrant special caution and expertise while attempting a device closure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Garg N, Madan BK. Hidden (end-on) patent ductus arteriosus: Recognition and device closure. Asian Cardiovasc Thorac Ann 2016;24:133-9.  Back to cited text no. 1
[PUBMED]    
2.
Garg N, Moorthy N. An alternative angiographic view to unmask the hidden patent ductus arteriosus during device closure. Catheter Cardiovasc Interv 2012;80:937-9.  Back to cited text no. 2
[PUBMED]    


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   Discussion
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