Asian Cardiovasc Thorac Ann 2002;10:72-74
© 2002 Asia Publishing EXchange Pte Ltd
Iatrogenic Coarctation After Coil Occlusion of Arterial Duct
Ümrah Aydo
an, MD,
Gülhis Batmaz, MD1,
Türkan Tansel, MD2
Departments of Pediatric Cardiology Istanbul Medical Faculty and
1 Cerrahpasa Medical Faculty
2 Department of Cardiovascular Surgery Istanbul Medical Faculty Istanbul University Istanbul, Turkey
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Ümrah Aydoan, MD Tel: 90 532 612 4719 Fax: 90 212 621 1643 email: uaydogan{at}turk.net Department of Pediatric Cardiology, Istanbul Medical Faculty, Istanbul University, Millet Caddesi, Çapa, Istanbul 34390, Turkey.
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ABSTRACT
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Coil occlusion of a patent ductus arteriosus was performed in an 8.5-month-old girl with a large left-to-right shunt through a wide arterial duct. Post-occlusion echocardiography revealed iatrogenic obstruction of the aorta caused by protrusion of the loops of the Jackson coil into the descending aorta. The problem resolved spontaneously during follow-up.
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INTRODUCTION
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Transcatheter occlusion of a patent ductus arteriosus (PDA) with spring coils has become an accepted nonsurgical treatment option in many centers. With a growing registry of patients, the procedure has been shown to be safe with few complications.1,2 Procedure-related flow disturbances in the descending aorta (DAo) are controversial.1,3,4 However, no flow disturbances in the DAo with diastolic runoff on Doppler echocardiography have been reported previously following coil occlusion of a PDA.
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CASE REPORT
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A baby girl was evaluated for a heart murmur a few days after birth. A small patent foramen ovale, a small ventricular septal defect, and a moderate-sized PDA were detected on echocardiography. She was put on digitalis, furosemide, and captopril. Her foramen ovale and ventricular septal defect closed spontaneously, but frequent lower respiratory tract infections, fatigue on feeding, and failure to thrive developed during follow-up, in spite of the aggressive anticongestive therapy. On hyperalimen-tation, at 8.5 months of age, her weight was only 6.4 kg. Her heart rate was 128 beats•min-1 with a grade 3/4 continuous murmur at the left upper sternal border. Electrocardiographic findings were biventricular hyper-trophy with left ventricular dominance and left atrial dilation. Doppler echocardiography demonstrated a left-to-right ductal shunt with a peak pressure gradient of 55 mm Hg. It was decided to close her PDA by coil implantation. An aortogram demonstrated a PDA with a fairly narrow ampulla, 3.5 mm at its minimal diameter. A Jackson coil (Cook Inc., Bloomington, IN, USA) with an 8-mm diameter and 5 loops was implanted transvenously (Figure 1
). Because of residual shunting, another coil with a 5-mm diameter and 4 loops was implanted via an arterial route during the same procedure. The implantation was uneventful and an angiogram revealed no residual shunt. Absence of ductal flow was confirmed the following morning by color Doppler echocardiography. However, on suprasternal two-dimensional echocardiography, a coil was seen to protrude into the aorta, producing turbulent flow. The peak pressure gradient was measured as 47 mm Hg with diastolic runoff in the DAo on continuous-wave Doppler echocardiography (Figure 2A). Physical examination showed no evidence of coarctation of the aorta; there were palpable femoral pulses and equal upper and lower extremity blood pressures. After 7.5 months, two-dimensional echocardio-graphy still showed a coil protruding into the DAo, but the aortic lumen was less compromised than in the previous investigation. There was still turbulent flow at the site of the coil. Continuous-wave Doppler echocardiography demonstrated that the peak systolic pressure gradient had decreased to 21 mm Hg, and there was no diastolic runoff (Figure 2B).
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Figure 1. Aortogram demonstrating residual ductal flow following implantation of an 8-mm 5-loop Jackson coil. Note the narrow ampulla causing distal loops of the coil to protrude into the descending aorta.
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Figure 2. Continuous-wave Doppler echocardiography (A) just after the occlusion procedure, demonstrating obstruction of the aorta with diastolic run-off, and (B) after 7.5 months of follow-up, demonstrating spontaneous resolution of the obstruction.
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DISCUSSION
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Concerns have been raised about potential aortic obstruction after coil occlusion of a PDA. It is generally agreed that coils placed in the ductus do not cause systolic pressure gradients across the juxtaductal aorta.5,6 However, minor flow disturbances may be seen in the DAo after PDA occlusion, due to insensitivity of Doppler turbulence to changes in flow velocity above the Nyquist limit.1,4 In one case, the Doppler echocardiographic flow velocity was measured as 2.1 m•s-1 in the DAo, but it normalized during intermediate follow-up.4 Progressive resolution of flow disturbance has been seen in other studies where it was attributed to endothelialization of the coils over time, with resultant incorporation of the protruding coil into the vessel wall, thus allowing unobstructed laminar flow.2,7 Moore and colleagues3 found a peak-to-peak pressure gradient of only 10 to 15 mm Hg across the site of a coil, on catheterization of a patient in whom the Doppler echocardiographic peak gradient was measured as 40 mm Hg. The catheterization gradient was attributed to the patient's mild isthmus hypoplasia.
Although there was a diastolic runoff on Doppler echocardiography in our patient, in view of the literature data and the expected increase in diameter of the aortic lumen with rapid weight gain on abolition of heart failure, it was decided not to perform another catheterization procedure to retrieve the coils. Echocardiographic evidence of obstruction in the DAo should be confirmed by early physical examination or catheterization before deciding on a course of action in such cases. However, our patient did not show any evidence of aortic obstruction on physical examination, and the Doppler echocardio-graphic gradient decreased during follow-up.
On the other hand, there are some reports of progressive increases in blood flow velocity in the DAo after coil occlusion of a PDA. In a study by Stromberg and colleagues,4 Doppler blood flow velocity in the DAo of one patient increased from 1.1 m•s-1 to 2.6 m•s-1 during follow-up. Similarly, in a patient of Moore and colleagues,3 the Doppler echocardiographic gradient in the DAo increased from 23 mm Hg just after the occlusion procedure to 40 mm Hg at 18 months. This phenomenon may be related to incomplete endothelialization of the coil during follow-up, which is unusual.
This experience shows that iatrogenic obstruction of the aorta related to coil occlusion of a PDA may resolve spontaneously, even when there is diastolic runoff on Doppler echocardiography. When the reports of incom-plete endothelialization are taken into consideration, it would seem prudent to choose a different occlusion procedure in such a patient with a narrow ampulla. If coil occlusion is preferred, then coils with fewer loops and a smaller diameter should be selected. A Jackson coil with a 6.5-mm diameter was not commercially available when this procedure was performed in our patient. Patient-coil mismatch should be avoided as it may cause descending aortic obstruction. If no suitable device is available, surgical closure should be performed as early as possible.
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REFERENCES
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Verma R, Lock BG, Perry SB, Moore P, Keane JF, Lock JE. Intraaortic spring coil loops: early and late results. J Am Coll Cardiol
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ABSTRACT
INTRODUCTION
