Pseudo interruption of the inferior vena cava complicating the device closure of patent ductus arteriosus: Case report and short review of venous system embryology
A nineteen-months-old girl presented with recurrent respiratory infection and patent ductus arteriosus (PDA). There was no other significant past medical or surgical history. An echocardiogram showed a 3.4 mm PDA with adequate ampulla and mild hyperkinetic pulmonary arterial hypertension. The patient was taken up for percutaneous device closure of the PDA. A diagnostic catheter (5 F Goodale Goodale-Lubin) from the right femoral venous access entered the right atrium through azygos vein into superior vena cava (SVC). A diagnosis of IVC interruption with azygos continuity was made. The PDA was crossed from venous end. The catheter course was via the right femoral vein, azygos vein, SVC, right atrium (RA), right ventricle, pulmonary artery, PDA to the descending aorta []. In view of the tortuous course, difficulty in tracking the delivery sheath was anticipated. Interventional options available in such a situation are: (a) Arterial side snaring of the distal end of the wire (for support), and tracking the femoral venous sheath, (b) Jugular venous approach, and (c) Trans arterial Amplatzer duct occluder II (ADO II). An ADO II device of appropriate size was not available then in the catheterization laboratory. Arterial side snaring was not attempted, anticipating cardiac stretch-related bradycardia. Therefore, the right internal jugular vein (IJV) access was used for PDA closure. An aortogram from the femoral arterial access showed 4.7 mm PDA. Through an 8F Mullin sheath, in the right internal jugular vein access, a 10 × 12 mm Heartr™ duct occluder device (Lifetech Scientific Inc., Shenzhen, China) was deployed. The post procedure angiogram and echo showed stable device position, with no residual flow. On the following day, a repeat echocardiogram revealed patent IVC connection into the right atrium. The patient was taken up for a venogram to rule out interrupted IVC. A right femoral venous angiogram showed filling of the iliac veins and azygos system, in addition to normal drainage into the IVC [Figures and , ]. Similarly, the left femoral venous angiogram showed filling of both the IVC and the hemi azygos system [, ]. Hence, the misdiagnosis of IVC interruption was revealed. The catheter has had tracked through the congenital communication between the iliac veins and the azygos system, bypassing the IVC. Had it been recognized earlier, internal jugular vein (IJV) access could have been avoided.