Asian Cardiovasc Thorac Ann 1999;7:204-208
© 1999 Asia Publishing EXchange Pte Ltd
Percutaneous Occlusion of Patent Ductus Arteriosus with Controlled-Release Coil
Arramraj Sreenivas Kumar, MD, DM,
Aditya Kapoor, MD, DM,
Nakul Sinha, MD, DM,
Madhukar Shahi, MD, DM,
Pravin Kumar Goel, MD, DM,
Sitaraman Radhakrishnan, MD, DM,
Savitri Srivastava, MD, DM
Department of Cardiology
Sanjay Gandhi Post-Graduate Institute of Medical Sciences
Lucknow, India
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For reprint information contact: Aditya Kapoor, MD, DM Tel: 91 522 44 0004 Ext 2225 Fax: 91 522 44 0017 email: akapoor{at}sgpgi.ac.in Department of Cardiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India.
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Abstract
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We evaluated the efficacy of the controlled-release Cook coil for percutaneous patent ductus arteriosus occlusion. Between October 1994 and December 1997, 45 consecutive patients with patent ductus arteriosus underwent cardiac catheterization and coil occlusion was attempted in 41, of whom 37 had Cook coils. A single coil was deployed in 34 of these patients and 2 or more coils were deployed in 3, with successful occlusion in 36 (97%). Immediate complete angiographic closure was achieved in 15 (41%), 18 (49%) had a trivial residual shunt, and 3 had a mild residual shunt on post-occlusion aortograms. Color Doppler echocardiography 24 hours after the procedure, revealed no detectable shunt in 33/36 (92%) and only a trivial residual shunt in 3 (8%) patients. Thus, 86% of patients with residual shunts immediately after occlusion had no evidence of residual shunts by 24 hours. No evidence of residual shunt or obstruction of the left pulmonary artery or the descending aorta was present at a mean follow-up of 26 months We concluded that Cook coils are a safe and cost-effective modality for percutaneous occlusion of patent ductus arteriosus with a high success rate and favorable intermediate-term follow-up.
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Introduction
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Transcatheter closure of patent ductus arteriosus (PDA) is a well-established method of treatment.1 Since its intro-duction by Porstmann and colleagues2 in 1971, several occluding devices and techniques have been developed.3–7 Percutaneous closure with single or multiple Gianturco coils has gained acceptance as an effective means of occluding small to moderate (4 mm or less) ducts.8–12 An important limitation of the use of these coils is the relative lack of controlled release, so that the coil cannot be withdrawn back into the delivery catheter at any stage. This is obviously associated with a potential for em-bolization, although it varies with operator experience. Several modifications have been developed to improve the positioning of coils and reduce the frequency of embolization.13–15 The Cook detachable coil (William Cook Europe A/S, Bjaeverskov, Denmark) is a modification of the Gianturco coil, which has a threaded extension at the proximal end that attaches to the distal threaded part of the delivery wire. These coils have recently been employed for occlusion of PDA with considerable success.16,17 The presence of a controlled-release mechanism allows good control over positioning of the coil and enables retrieval back into the delivery catheter or repositioning of the device if its position is deemed suboptimal by the operator. We report our initial experience with Cook detachable coils and the intermediate-term follow-up.
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Patients and Methods
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Between October 1994 and December 1997, cardiac catheterization was carried out in 45 consecutive patients with PDA, of whom 41 underwent attempted percutaneous occlusion. Gianturco coils were employed in the first 4 patients. Cook coils were used in the last 37 patients comprising 25 females and 12 males with a mean age of 10.7 ± 9.8 years (range, 4 months to 40 years) and mean weight of 10 ± 6 kg (range, 4 to 42 kg). Thirty-four patients were asymptomatic and the other 3 were in New York Heart Association functional class II. One patient had a residual shunt after surgical ligation of a PDA and one had a mild residual shunt after occlusion with a single Gianturco coil 10 months previously.
Right and left heart catheterization was performed in all patients via the femoral vein and artery. Intravenous ketamine and diazepam were used for sedation in the pediatric patients and intramuscular diazepam alone in adult patients. Antimicrobial prophylaxis in the form of intravenous cefotaxime 30 mg•kg–1 was given to all patients. Aortic angiograms were performed in the lateral view to delineate ductal morphology and the size of the duct was measured at its narrowest point. The size of coil chosen was such that its helical diameter was at least twice the narrowest width of the duct with a length sufficient for a minimum of 3 loops.8
Cook detachable coils are available in 3 mm, 5 mm, 8 mm diameter sizes with the number of loops varying from 3 to 5. These stainless-steel coils with Dacron meshes differ from Gianturco coils by having a thread at the proximal end and an inner core extending to the distal end. The coil is supplied preloaded into a cartridge with a flared end. The delivery system consists of a coil delivery wire (0.038 inch) with a central core and a thread at the proximal end of the wire with a straightening mandril at the distal end and a handle. A pin vise is provided, which can be advanced into the delivery wire and used to apply torque (Figure 1
). To deliver the coil into the duct, the straightening mandril (b) is advanced into the delivery wire to protrude through the delivery wire (f) as shown in Figure 2A. The mandril (b) is introduced into the flared end of the coil loading cartridge (i) and into the center of the threaded part of the coil (g) to stiffen and keep it straight during insertion and subsequent advancement into the delivery catheter (Figure 2B). The loading cartridge (i) is advanced until the thread of the coil and delivery wire (f) meet (Figure 2C). The loading cartridge (i) is rotated clockwise to engage the whole length of the coil (g), which usually requires 8 whole turns (Figure 2D). The loading cartridge is rotated counter clockwise once, leaving a gap of 1 mm between the thread of the delivery wire (f) and the coil (Figure 2E). The coil is kept straight by advancing the straightening mandril until it reaches the tip of the coil (Figure 2F). The delivery catheter, a 4 or 5 end-hole catheter with a 0.04-inch internal diameter (William Cook, Europe A/S, Bjaeverskov, Denmark) is positioned across the ductus, the straightening mandril is withdrawn and the delivery wire is advanced to protrude 1 or 2 loops into the pulmonary artery (or descending aorta, depending on whether the route of coil delivery is retrograde or anterograde) as shown in Figure 3A. The whole assembly is then withdrawn into the aortic ampulla to engage the protruded loops in the pulmonary side of the duct (Figure 3B). The straightening mandril is withdrawn proximal to the coil and the catheter over the coil is withdrawn until it is just proximal to the attachment point of the coil (Figure 3C). The delivery wire is advanced to form loops in the aortic ampulla and the coil is detached by making anticlockwise turns of the delivery wire. The coil remains entirely retrievable until this last manoeuvre is performed, thus ensuring satisfactory placement (Figure 3D).
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Figure 2. Preparation of the Cook coil for delivery. See text and Figure 1 for description of components.
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All patients were discharged within 24 hours after a post-procedure chest radiograph and an echocardiogram. Clinical and echocardiographic follow-up was carried out at 3 months and then every year.
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Results
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The mean PDA size was 2.6 ± 0.7 mm (range, 1.6 to 3.9 mm). Thirty-four patients had a type-A PDA and 3 had type C.18 Mean pulmonary artery pressures ranged from 16 to 52 mm Hg (mean, 22.2 ± 5.6 mm Hg). A single coil was placed in 34 of the 37 patients. Occlusion was performed with 2 coils in 2 patients and by sequential delivery of 3 coils in the patient who had previously had a single Gianturco coil inserted. The anterograde approach was used for coil delivery in 22 patients and the retrograde approach in 15. Twenty-nine 8-mm coils and 12 5-mm coils were used (41 coils in 37 patients). The procedure was successful in 36 of the 37 patients (97%). One patient with a type-C PDA was referred for surgical closure when coil occlusion was found to be unsuccessful.
Complete angiographic occlusion of the duct was achieved in 15 of the other 36 patients (41%), 18 (50%) had a trivial shunt, and 3 had a mild residual shunt in the immediate post-occlusion aortic angiogram. The continuous murmur was abolished in all patients. Color Doppler echocardiography 24 hours after the procedure, revealed no residual shunt in 16 of the 18 patients with trivial residual shunt at angiography. Of the 3 patients with mild residual shunt at angiography, there was no detectable shunt at 24 hours in 2 and the other had a trivial residual shunt. Thus, at 24 hours, complete closure had occurred in 33/36 (92%). Eighteen of the 21 patients with a trivial to mild shunt immediately after occlusion, had no detectable shunt by 24 hours. Of the 3 patients with trivial shunt at 24 hours, none had a detectable shunt at 1 month.
At a mean follow-up of 26 months (range, 9 to 36 months) no patient had evidence of residual shunt, coil embolism or migration, or obstruction of flow in the left pulmonary artery or descending aorta. Coil embolization occurred in 3 patients. In the first of these cases where the duct size was 2.6 mm, a 5-mm 5-loop coil embolized to the left pulmonary artery and was retrieved, an 8-mm 5-loop coil was then successfully deployed. In the second case where the duct size was 2.4 mm, a 5-mm 3-loop coil that appeared to be in a satisfactory position in the duct, embolized after a few minutes. The coil was immediately retrieved and an 8-mm 5-loop coil was successfully deployed. In the third patient, the coil could not be retrieved and was left in situ in the distal left pulmonary artery. The duct was successfully occluded using another coil of the same size (a 5-mm 5-loop coil in a 2.1-mm duct). Hemolysis was encountered in one of the patients with a mild residual shunt after occlusion, which subsided spontaneously during the first week and the patient did not require repeat coil occlusion.19
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Discussion
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Transcatheter coil occlusion of persistent PDA is the procedure of choice for closure of small ducts and it is rapidly gaining popularity for large ducts (more than 4 mm) where multiple coils are deployed.8–12 However, the lack of controlled release with the Gianturco coil has resulted in embolization at rates varying from 6% to 10%.10,20,21 The Cook detachable coil is a modification of the Gianturco coil, enabling controlled release and retrieval of the coil intact up to the point of delivery. This provides better control over positioning of the coil and a lower rate of embolization.
Complete angiographic closure of PDA immediately after coil occlusion has been reported to vary from 33% to 90%.8,12,20–22 Immediate complete angiographic occlusion using Cook detachable coils was achieved by Uzun and colleagues16 in 60% of cases. In our experience, 92% had either trivial (50%) or no residual shunt (41%) on the immediate post-occlusion angiogram. We did not implant a second coil unless we found persistence of a continuous murmur with mild residual shunting in the immediate post-occlusion angiogram. Although Hijazi and colleagues12 aimed for complete angiographic closure of the duct in the catheterization laboratory, small residual shunts often resolve spontaneously and may not need multiple coil delivery. Uzun and colleagues16 reported that it was difficult to predict which residual shunts would disappear spontaneously. They performed an echo-cardiogram in the catheterization laboratory following coil occlusion and did not implant a further coil if there was no audible murmur and the shunt jet on color Doppler was narrow. Residual shunts after coil occlusion have shown spontaneous closure over 3 to 6 months of follow-up.16,21,23,24 In our series, 18 of the 21 patients (86%) who had trivial to mild residual shunts on post-occlusion angiography, had no detectable shunt at 24 hours. In the 3 patients with trivial residual shunt at 24 hours, there was no detectable shunt at 3 months, giving an occlusion rate of 100% at 3 months. At a mean follow-up of 26 months, there was no residual shunt detected by echocardiography and no late complications. In the only other reported study of Cook detachable coils with more than 6 months of follow-up, Shim and colleagues23 detected no incidence of late coil migration, endarteritis, hemolysis, or obstruction at the level of the left pulmonary artery or aorta. Arora and colleagues25 noted a 4/20 (20%) incidence of residual shunt at 24 hours in their report of short-term follow-up.
We encountered coil embolization in 3 patients, 2 of whom were treated early in the series. In the last 18 patients, we encountered only one case of coil em-bolization, reflecting improvement with operator experience. Careful selection of coil size after proper sizing of the PDA is an important factor in avoiding embolization and failure of the procedure. Our embolization rate compares favorably with other reports. Uzun and colleagues16 encountered 5 cases of embolization in their experience with Cook coils. As found in our study, occasionally coils can be left in situ without any untoward effects.12,16,21 In the patient in whom we had to leave the coil in situ in the distal left pulmonary artery, a ventilation-perfusion scan did not reveal any significant abnormality and the patient was well at the last follow-up at 12 months. Although a type-C PDA may pose difficulties during closure with the umbrella device, this may not be true for occlusion with a coil because it can configure more closely to the shape of the duct.18,23,25 The only failure in our series was in a case of type-C PDA and we referred the patient for surgery. However, we feel that with increasing experience, such ducts can be successfully occluded with coils and we have carried this out in subsequent cases of type-C PDA.
This study comprised a limited number of patients and the long-term effects of this device need to be further assessed as our follow-up extended to only 26 months. However, our findings indicate that percutaneous occlusion of a persistent arterial duct using the controlled-release Cook coil is safe and effective in experienced hands. Careful sizing of the duct and analysis of its morphology has an important role in the prevention of embolization and achievement of higher rates of occlusion.
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References
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Abstract
Introduction
