Percutaneous closure of patent ductus arteriosus in interrupted inferior caval vein through femoral vein approach
A 12-year-old girl who presented with dyspnea on moderate exertion and palpitation since three years was admitted for percutaneous closure of a patent arterial duct. Her infancy and childhood period were unremarkable and without cardiac symptoms. Her weight was 39 kg and height was 149 cm. Her blood pressure was 120/60 mmHg. Peripheral pulses were bounding. Precordial examination revealed active precordium with the point of maximum intensity shifted downward and laterally. There was thrill and continuous murmur over the left second intercostal space. Chest X-ray showed marked cardiomegaly. Electrocardiogram (ECG) showed sinus rhythm with a rate of 80 bpm and left ventricular hypertrophy. Echo showed dilated left atrium, left ventricle, and pulmonary artery, and a patent ductus arteriosus (PDA) of about 6 mm with a continuous left-to-right shunt.\nUnder general anesthesia, arterial access was established through the right femoral artery with a 4F introducer and aortic pressure was measured (86/53 mmHg, mean: 69 mmHg). Then, aortic angiogram was done []. A duct measuring 5 mm was seen. On right heart catheterization, it was found that the inferior caval vein was interrupted and that there was azygos continuation. A Terumo catheter was advanced and snared in the descending aorta. An AGA exchange wire (.035" × 260 cm) was advanced through the catheter and snared in the descending aorta. While snaring the wire, an Amplatzer TorqVue 2 delivery sheath 6F, 60 cm long (AGA Medical Corporation, Golden Valley, MN) was advanced over the wire from the venous side and again snared in the descending aorta [Figures and ]. An Amplatzer duct occluder (ADO) size 8/6 was advanced through the sheath while still holding the sheath with a snare [Figure –]. The device was opened, again with the sheath still snared. The sheath was then unsnared once the aortic disc was completely out. The sheath and the device were pulled back into the duct and the device was successfully implanted []. The device was then released and it attained a stable position []. An aortic angiogram was done after the device was released, showing complete occlusion. The patient remained stable and there was no hemodynamic instability anytime during the procedure. She was extubated immediately.