Interact CardioVasc Thorac Surg 2009;8:689-690. doi:10.1510/icvts.2008.201152
© 2009 European Association of Cardio-Thoracic Surgery
Surgical removal of an embolized patent ductus arteriosus coil from pulmonary artery without cardiopulmonary bypass
Hakan Aydin and
Kanat Ozisik*
Department of Cardiovascular Surgery, Sami Ulus Children's Hospital, Ankara, Turkey
Received 23 December 2008;
received in revised form 18 February 2009;
accepted 18 February 2009
*Corresponding author. Birlik mah. 9. cad. No: 107/12, Çankaya, Ankara, Turkey. Tel.: +90-505-2901885; fax: +90-312-3100378.
E-mail address: sozisik2002{at}yahoo.com (K. Ozisik).
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Abstract
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We report the case of a 4-month-old girl who underwent patent ductus arteriosus (PDA) coil embolization. The coil had migrated into the left pulmonary artery and attempts to retrieve it with interventional techniques were unsuccessful. To prevent late effects of a foreign object in pulmonary artery, the patient was referred to surgery. The operation was done without cardiopulmonary bypass (CPB) and with the aid of a Fogarty catheter. Recovery was uneventful after the procedure. As far as we know this is the first patient in whom CPB was not used for coil removal.
Key Words: Patent ductus arteriosus; Coil embolization; Fogarty catheter
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1. Introduction
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Recently, less invasive methods for closure of patent ductus arteriosus (PDA) have gained popularity, such as thoracoscopic clipping, extrapleural clipping or ligation with mini-thoracotomy and interventional catheter techniques [1–3]. After initially being introduced by Porstman et al., alternative strategies of non-surgical closure of PDA have gained increasing attention after the report by Gianturco et al. [4, 5]. Thereafter, several devices have been used for interventional closure of PDA with varying success rates. Although, results of closure with these devices have been reported to be satisfactory, some complications have been reported after these procedures. The complications of interventional treatment include lack of closure, embolization, left pulmonary artery stenosis, femoral puncture site problems, and hemolysis [6].
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2. Case report
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A four-month-old girl weighing 4850 g underwent elective transcatheter coil (Ductocclud, PFM Coil, PFM AG, Cologne, Germany) embolization with diagnosis of moderate-size PDA. During the procedure, following its release from the connector, the coil had migrated and embolized to the left pulmonary artery (Fig. 1). The coil was seen to be embedded at the lower segment branch of the left pulmonary artery. Concerted effort of interventional cardiologists for removing the coil failed after two hours. The coil could not be retrieved despite the use of snare, basket and loop techniques. The coil was lodged and entrapped so tightly that even a millimeter of movement was impossible. After failure of all these attempts, the baby was referred to our surgical unit urgently. Although the patient remained hemodynamically stable during the procedure, closure of PDA and removal of the coil was deemed necessary due to its long-term effects.
The procedure was planned to be held without cardiopulmonary bypass (CPB) and carried out through left thoracotomy. The PDA was divided with double ligation. Then hilus of the lung was dissected and pulmonary veins were suspended with silastic loop in order to reach the pulmonary artery and its major branches. After reaching the left main pulmonary artery, dissection was further carried toward the lower segment artery and it was so palpated that the coil was lodged at the very distal part of the artery in lung tissue where it is impossible to remove with simple arteriotomy. As we planned before, we decided to use a Fogarty catheter in order to remove this foreign object as described previously [7]. A small arteriotomy was made at a branching point of the pulmonary artery and a 4F Fogarty catheter was introduced. At first attempt we failed to remove it but the second attempt was successful (Fig. 2). Then, we flushed the artery with heparinized solution and repaired the arteriotomy with deairing proximally and distally. Pulmonary circulation was restored. Thoracotomy was closed in a standard fashion with a small chest tube for drainage. The patient was heparinized with low molecular weight heparin for five days postoperatively. Chest tube was removed the day after surgery and the patient was discharged on the fifth postoperative day without any problem.
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3. Discussion
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Technological advances in cardiology have made non-surgical interventions of PDA simple and routine procedure. However, there are situations where complications are encountered, and surgery is required in these patients when interventional methods fail. Embolization of the device was seen in 3.8% of the cases, and occurs more commonly to the pulmonary circulation than to the systemic circulation because of the pressure gradient between them [8]. In our opinion, any embolized material into the pulmonary arterial tree must be removed as early as possible because of the risk of adherence and endothelization which increase technical difficulty of removal later. Usually, the surgical removal is done immediately after catheterization to prevent inflammatory reaction of the foreign material [9]. According to our knowledge, all surgical attempts to remove these devices were done with the aid of CPB technique [9, 10]. The main standpoint of the method was avoiding sternotomy and CPB for preventing problems of resternotomy in adulthood. Avoiding CPB is a well-known benefit in cardiac surgery for appropriate patients.
In our case, we present a new technique for removal of a foreign object which does not predispose the patient to adverse effects of CPB and sternotomy. This will prevent adhesions which may complicate any other cardiac surgical procedure later in life. This novel method can easily be used for migrated coils to the left side, which also enhances closure of the PDA in standard fashion through left thoracotomy. In cases of migrated coils to right lung vasculature, sternotomy may be used for both PDA ligation and coil removal again without CPB.
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References
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- Jatene FB, Assad RS, Pêgo-Fernandes P, Jatene MB, Monteiro R, Aiello VD, Rocha e Silva R, Barbero-Marcial M, Jatene AD. Video-assisted surgery for closure of patent ductus arteriosus. Study in sheep and initial clinical experience. Arq Bras Cardiol 1994;63:469–472.[Medline]
- Miles RH, Delcon SY, Muraskas J, Myers T, Quinones JA, Vitullo DA, Bell TJ, Fisher EA, Pifarre R. Safety of patent ductus arteriosus closure in premature infants without tube thoracostomy. Ann Thorac Surg 1995;59:668–670.[Abstract/Free Full Text]
- Allen HD, Beekman RH III, Garson A, Hijazi ZM, Mullins C, O'Laughlin MP, Taubert KA. Pediatric therapeutic cardiac catheterization. A statement for healthcare professionals from the council on cardiovascular disease in the young, American Heart Association. Circulation 1998;97:609–625.[Free Full Text]
- Porstmann W, Wierny L, Warnke H. Closure of persistent ductus arteriosus without thoracotomy. Ger Med Mon 1967;12:259–261.[Medline]
- Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Roentgenol Ther Nucl Med 1975;124:428–435.
- Jang GY, Son CS, Lee JW, Lee JY, Kim SJ. Complications after transcatheter closure of patent ductus arteriosus. J Korean Med Sci 2007;22:484–490.[Medline]
- Ayd
 n H, Koçer B, Albayrak D, Dural K. Surgical removal of a migrated guidewire: a safe method. Anadolu Kardiyol Derg 2007;7:327–328.[Medline] - Magee AG, Huggon IC, Seed PT, Qureshi SA, Tynan M. Transcatheter coil occlusion of the arterial duct. Results of the European registry. Eur Heart J 2001;22:1817–1821.[Abstract/Free Full Text]
- Atik FA, Jatene FB, Costa PHN, Atik E, Barbero-Marcial M, de Oliveira SA. Surgical treatment of coil embolization to the pulmonary artery after an attempt at percutaneous closure of patent ductus arteriosus. Arq Bras Cardiol 2004;83:80–82.[Medline]
- Shahabuddin S, Atiq M, Hamid M, Amanullah M. Surgical removal of an embolised patent ductus arteriosus amplatzer occluding device in a 4-year-old girl. Interact CardioVasc Thorac Surg 2007;6:572–573.[Abstract/Free Full Text]
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Abstract
1. Introduction
