Percutaneous device closure of persistent ductus venosus presenting with hemoptysis
An eight-year-old boy, presented with a history of hemoptysis (50 ml per episode, thrice) for one week. The X-ray of the chest was unremarkable and the screening echocardiography was normal. Pulse oximetry and blood gas showed oxygen saturation of 80%, when the patient was comfortable at rest. Contrast echo with agitated saline done to rule right to left shunt, showed delayed appearance of bubbles in the left atrium after four cycles, suggestive of pulmonary arteriovenous fistula (PAVF). Contrast-enhanced computed tomography (CECT) revealed two small (2 mm) aortopulmonary collaterals at T6 - T7, one on each side, no major PAVF, features of aspiration in the right upper lobe, and an incidentally detected persistent ductus venosus (PDV) []. The ultrasonogram and echocardiography confirmed a PDV of 6.5 mm diameter, opening into the inferior vena cava (IVC) [ and ] and no evidence of liver disease or portal hypertension. The diagnosis of congenital portosystemic shunt due to PDV, causing PAVF was made. The aortopulmonary collateral arteries (APCA) were considered to be secondary to systemic hypoxemia. However, the cause of hemoptysis was not clear (aortopulmonary collateral or PAVF). The patient was taken up for percutaneous intervention of PDV and aortopulmonary collateral. A pulmonary angiogram showed diffuse bilateral multiple small PAVFs []. The PDV was entered from the internal jugular vein access. Test balloon occlusion showed adequate hepatic portal circulation and no increase in portal pressure from the basal 10 mmHg [ and ]. Through a 7F Mullin sheath, a 12 mm Amplatzer vascular plug II (St. Jude Medical, St. Paul, Minnesota) was deployed [ and ]. The APCAs on both sides were selectively cannulated []. The right APCA was cannulated with a 4F right coronary artery (RCA) catheter and coiled with two 035 inch 2 mm – 30 mm platinum fiber coils (COOK MEDICAL INC. Bloomington). The left APCA could not be coiled. There was no recurrence of hemoptysis in the next 48 hours and the patient was discharged. The follow-up plan was to monitor the oxygen saturation for regression of PAVF and an ultrasonogram to rule out portal hypertension.