Complications after PDA Closure: A Coarctation Situation

Arpan R. Doshi, MD

We present a patient who had closure of patent ductus arteriosus (PDA) with a Gianturco-Grifka Vascular Occlude Device (GGVOD) in early infancy. Although the patient was reported to have mild gradient after PDA closure, it was felt to be insignificant by the cardiologist performing the procedure. During follow-up with us, we noted development of significant aortic coarctation. Given the significant protrusion of the device components into the aortic lumen (Figure 1), we may have to conclude that the bulky device is responsible for the development of coarctation in our patient.

When we detected aortic coarctation at age 6, we performed less invasive balloon angioplasty because of growth issues related to stents in younger children. Improvement with mild residual gradient (10 mm Hg) and lack of systemic hypertension led us to advise periodic clinical follow-up. When she developed significant obstruction at age 12 (weight, 40 kg), we went ahead and implanted a stent across the narrowed aortic segment, relieving the obstruction (Figure 2). During a 3-year follow-up after stent placement, no recurrence was detected. Longer-term follow-up may result in development of obstruction, when dilatation of the stent may be required.

In the presence of both PDA and aortic coarctation, it is generally recommended that both are dealt with either surgically or through catheter intervention that can address both issues. However, in some cases, the coarctation gradient may be fictitious secondary to increased flow across the aortic isthmus. If the coarctation is fictitious, the gradient will be abolished by test occlusion of the ductus and surgery avoided.

We report a case of coarctation of aorta that developed after GGVOD occlusion of PDA which is believed to be due to bulky device encroaching into the lumen of the aorta. The patient had complete resolution of the coarctation after transcatheter stent implant. Modification of existing devices so that they may not cause aortic obstruction and avoidance of use of large devices in small babies may improve outcomes of PDA closure.

Image

Figure 1. Selected cineangiographic frames in 20° left anterior oblique (A) and straight lateral (B) views demonstrating protrusion of the Gianturco-Grifka Vascular Occlude Device (GGVOD) coils into the aorta, particularly seen in the lateral view (B). Note slight posterior indentation (PI) in the lateral view (B). DAo = descending aorta; LSA = left subclavian artery.

Image

Figure 2. Selected cineangiographic frames in straight lateral views (A) prior to and (B) following stent implantation demonstrating the aortic obstruction caused by the Gianturco-Grifka Vascular Occlude Device (GGVOD) coils (A) is completely abolished after implantation of the stent (B). DAo = descending aorta; LSA = left subclavian artery; Sh = tip of the sheath.

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