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Asian Cardiovasc Thorac Ann 2001;9:330-331
© 2001 Asia Publishing EXchange Pte Ltd

CASE STUDY

Surgical Retrieval of Malpositioned Ductal Coil

Sowrangshu Kumar Chowdhury, MCh, Madathil Sahadevan Ranjit, MD, Richard Saldanha, MCh, Komarakshi Rajagopalan Balakrishnan, MCh

Department of Cardiothoracic and Vascular Surgery Sri Ramachandra Medical College University Hospital Chennai, Tamil Nadu, India
For reprint information contact: Richard Saldanha, MCh Tel: 91 44 476 9033 Fax: 91 44 476 7008 email: rsaldanha56{at}hotmail.com Department of Cardiothoracic and Vascular Surgery, Sri Ramachandra Medical College University Hospital, Porur, Chennai, Tamil Nadu 600116, India.

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A 3.5-year-old girl underwent transcatheter closure of a patent ductus arteriosus, which resulted in severe hemolysis. The malpositioned coil was surgically retrieved under cardiopulmonary bypass.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Transcatheter closure of a patent ductus arteriosus (PDA) using coils is becoming increasingly popular because of its superior cost effectiveness, high success rate (97% to 100%), avoidance of anesthesia and surgery, and thereby avoiding an unsightly scar.1–3 It can achieve the same closure rate as surgery with fewer complications.4 However, residual shunt and coil embolization remain potential complications of this procedure; both may lead to hemolysis that can be fatal.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 3.5-year-old girl with an asymptomatic large PDA (5 mm) underwent transcatheter closure with a 0.52-inch 5-loop Cook coil (Cook, Inc., Bloomington, IN, USA). She developed acute hemolysis 24 hours after the procedure, which initially settled but later recurred and became progressive. She was referred to our hospital 13 days after the procedure with severe hemolysis, epistaxis, melena, oliguria, hematuria, and acute renal failure. On examination, the child was drowsy, toxic, and in extremis with fever, pallor, and jaundice. She had a hemoglobin level of 8.1 g•L-1, a packed cell volume of 23.8%, a red blood cell count of 2.71 x 106/mm3, and a total leukocyte count of 22,500/mm3. The platelet count was 2,250,000/mm3, the bleeding time was 2 minutes and 15 seconds, and the clotting time was 5 minutes and 45 seconds. Other biochemical examinations could not be carried out because of the severe hemolysis. The clinical picture was suggestive of disseminated intravascular coagulation. Besides hemolysis due to the malpositioned PDA coil, sepsis was also considered as an etiologic factor in the clinical and laboratory manifestations, but a preoperative blood culture did not grow any organism. Chest radiography showed cardiomegaly, mildly plethoric lung fields, and the PDA coil in situ (Figure 1Go). An echocardiogram revealed a large 5-loop coil sitting partially in the pulmonary end of the PDA with 2 loops abutting the right pulmonary artery with organized clots and right pulmonary artery stenosis (Figure 2Go). The PDA measured 5.0 to 5.5 mm in diameter, there was a moderate left-to-right shunt through the coil, and normal pulmonary artery pressures with moderate left heart and pulmonary artery dilatation. The child was stabilized with blood transfusions, antibiotics (cefotaxime), and decongestive therapy for 24 hours before emergency coil removal and surgical closure of the PDA. Through a median sternotomy, the aorta and right atrium were cannulated, the ductus was dissected intrapericardially and looped, cardio-pulmonary bypass (CPB) was initiated, and the patient was cooled to 34°C. The main pulmonary artery was opened, the PDA coil was removed along with the clots, and the artery was closed with 4/0 polypropylene suture. The ductus was interrupted with double ligation and clipped. The patient was rewarmed and weaned easily from CPB. She continued to be febrile (37.5°C to 38°C) for 3 days. Postoperative blood cultures were negative but urine culture grew Escherichia coli. Her fever settled after antibiotic treatment and she was discharged from the hospital on the 10th postoperative day. Three months later, she was well with a nonspecific ejection systolic murmur at the left second intercostal space. Chest radiography showed a small heart with normal pulmonary vascularity. An echocardiogram showed no residual PDA but there was mild stenosis of the right pulmonary artery with a gradient of 5 mm Hg.



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  		Figure 1. Chest radiograph showing the Cook coil in the ductus and right pulmonary artery.

 


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  		Figure 2. Echocardiogram showing the position of the coil partially in the ductus and the right pulmonary artery. AO = aorta, DAO = descending thoracic aorta, PA = pulmonary artery, PDA = patent ductus arteriosus.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
The accepted treatment for acute hemolysis following transcatheter closure of a ductus arteriosus is immediate deployment of a second device without retrieving the first device.5 Coil malposition or migration can also be easily corrected by retrieval with a 10-mm nitinol snare catheter.6 Tomita and colleagues7 stressed that residual leaks should be minimized by using multiple coils. In our patient, it was not possible to carry out either of these treatment options because she was referred very late and in a moribund condition with acute renal failure and suspected disseminated intravascular coagulation, as well as clots attached to the coil. There was also a high risk of dislodging the clot around the coil, which was clearly visible on echocardiography. Transcatheter retrieval was not attempted as the 5-loop 0.52-inch Cook coil is very stiff and there was a likelihood of tearing the inflamed and friable PDA or the pulmonary arteries; thus surgery was considered the best option. There have been previous reports of emergency surgical intervention including removal of a coil from the right ventricle under CPB after unsuccessful attempts to retrieve it with snares, baskets, and bioptomes, as it had become entangled in the tricuspid valvular apparatus.8 It was decided to use CPB in this case because it enabled the coil to be retrieved easily and safely. There were no adverse effects of CPB as the duration was only 6 minutes. In cases of a malpositioned ductal coil with resultant severe hemolysis where catheter retrieval is unsuccessful, early surgery which is safe and effective should be considered.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Singh TP, Morrow WR, Walters HL, Vitale NA, Hakimi M. Coil occlusion versus conventional surgical closure of patent ductus arteriosus. Am J Cardiol 1997;79:1283–5.[Medline]

  2. Hijazi ZM, Geggel RL. Transcatheter closure of patent ductus arteriosus using coils. Am J Cardiol 1997;79: 1279–80.[Medline]

  3. Ing FF, Sommer RJ. The snare-assisted technique for transcatheter coil occlusion of moderate to large patent ductus arteriosus: immediate and intermediate results. J Am Coll Cardiol 1999;33:1710–8.[Abstract/Free Full Text]

  4. Zellers TM, Wylie KD, Moake L. Transcatheter coil occlusion of the small patent ductus arteriosus (< 4 mm): improved results with a "multiple coil-no residual shunt" strategy. Cathet Cardiovasc Interv 2000;49:307–13.

  5. Wang LH, Wang JK, Mullins CE. Eradicating acute hemolysis following transcatheter closure of ductus arteriosus by immediate deployment of a second device. Cathet Cardiovasc Diagn 1998;43:295–7.[Medline]

  6. Lee ML, Chaou WT, Wang JK. Transcatheter occlusion of patent ductus arteriosus with Gianturco coils in pediatric patients: a preliminary result in central Taiwan. Int J Cardiol 1999;69:57–63.[Medline]

  7. Tomita H, Fuse S, Akagi T, Matsumoto Y, Murakami Y, Shiraya H, et al. Hemolysis complicating coil occlusion of patent ductus arteriosus. Cathet Cardiovasc Diagn 1998; 43:50–3.[Medline]

  8. Fulwani MC, Vajifdar B, Tendolkar AG, Dalvi BV. Coil entrapment in the tricuspid valve apparatus requiring surgical removal; an unusual complication of transcatheter closure of patent ductus arteriosus. Indian Heart J 1999; 51:77–9.[Medline]




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