Cardiovascular Intervention and Therapeutics

Percutaneous Closure Of Atrial Septal Defect Via Transjugular Approach With Blockaid Device In A Patient With Interrupted Inferior Vena Cava
--Manuscript Draft-Manuscript Number: Full Title: Article Type: Abstract: CVIT-D-11-00045R1 Percutaneous Closure Of Atrial Septal Defect Via Transjugular Approach With Blockaid Device In A Patient With Interrupted Inferior Vena Cava Case Report ABSTRACT Percutaneous ASD closure was done successfully through internal jugular approach in a 40-year old female with IVC interruption and azygos continuation. This case demonstrates the feasibility of transcatheter ASD closure in difficult anatomy which precludes standard transfemoral approach. Reviewer 1: NEW figures showing IVC interruption and azygos joining the SVC have been provided clarifying the anatomy. 2.Minor syntactical errors are corrected. Reviewer 2: 1. The appropriate details pertaining to the hardware like the name of the manufacturing company, the size etc of the hardware are given in detail. 2.Minor suggested revisions have been done 3.Our experience with TTE guidance has been briefly mentioned. Reviewer 3: 1.The TTE guidance is a routine in our centre.We decide about the anchorage of the device from apical 4 & 5 chamber and basal short axis views. 2.Additional figure showing delivery sheath in both LUPV & LLPV were provided 3.Minor corrections were made

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Percutaneous Closure Of ASD Via Transjugular Approach With Blockaid Device In A Patient With Interrupted IVC SHORT TITTLE: TRANSJUGULAR DEVICE CLOSURE OF ASD
Seshagiri Rao.D, Patnaik A. N, Srinivas.B*

Department of Cardiology, Nizams Institute of Medical Sciences, Hyderabad, AndhraPradesh, India - 500 082

*Correspondence to : B.Srinivas, Department of Cardiology, Nizams Institute of Medical Sciences, Hyderabad, AndhraPradesh, India - 500 082. E-mail: srinivas_bh2005@yahoo.com.

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ABSTRACT
Percutaneous ASD closure was done successfully through internal jugular approach in a 40-year old female with IVC interruption and azygos continuation. This case demonstrates the feasibility of transcatheter ASD closure in difficult anatomy which precludes standard transfemoral approach. Key words: Atrial septal defect; venous anomaly; Intervention

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INTRODUCTION Percutaneous closure of ostium secundum atrial septal defect(ASD) is now a well established

treatment modality. The route of deployment is through the femoral venous approach and the devices are designed for that route. But, rarely, it may not be possible to deploy through the inferior vena cava (IVC) route ,especially if there is an interruption. In such a situation, an alternative route like

transjugular approach should be considered.

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CASE REPORT A 40 year old female patient was evaluated for exertional dyspnea of 2 years duration and diagnosed as having a large ostium secundum ASD. She was referred to our centre for possible device closure. On evaluation she was found to have a secundum ASD which was suitable for device closure The defect was measuring 26mm on transesophageal echocardiography (TEE). IVC interruption with azygos continuation was noted. Hence transjugular device deployment was planned. The procedure was performed under fluoroscopic and trans thoracic echocardiographic guidance under local anaesthesia. 6French (6F) introducers were placed in right femoral vein and artery. An IVC gram was done to demonstrate IVC interruption (Figure 1)with azygos continuation(Figure 2) A 7French(7F) introducer (Cordis) was introduced through the right internal jugular vein. A 6F internal mammary artery (IMA) catheter was used to cross the ASD with Radi focus straight tip (Terumo CORP) guidewire (0.035x150cm). Difficulty in crossing the ASD was experienced which was overcome by advancing the guidewire and IMA catheter directed posteriorly rather than in right to left direction. After crossing the ASD, the guidewire was exchanged with 0.035 Amplatz extra stiff guidewire (Cook, Indianapolis). Then, 34mm Amplatz sizing balloon was used to size the ASD. 12 F,60cm single curve delivery sheath (Shanghai shape memory alloy company limited, shanghai, China) was introduced into left atrium which required repeated attempts as the Amplatz stiffwire was prolapsing into right atrium( RA) with the advancement of the sheath. Attempt to orientate the wire and sheath towards left upper pulmonary vein( LUPV) was given up as the acute U shaped curve (Figure 3)on the sheath affected the stability and the assembly was placed in left atrium(LA) in such a way as to face the Left lower lobe pulmonary vein(LLPV) (Figure 4). Then, a 30mm Blockaid ASD occluder (Shanghai shape memory alloy company limited, shanghai ,China) was introduced after due precautions like careful aspiration and flushing. The 4

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device was prolapsing into left ventricle( LV) or obstructing the LV inflow on releasing the LA disc. Hence the LA disc was released by directing the sheath-device assembly towards LA free wall and the RA disc was released later successfully. The position of the device was confirmed by 2D Echo and RA angiogram (Figure 5).

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DISCUSSION Percutaneous closure of ASD was first reported in 1974(1). All the available devices are meant to be delivered via femoral venous route. But, in an occasional case, it may not be possible to deploy the device through the femoral route if the IVC is obstructed which may be congenital or acquired. Acquired obstruction may be due to an insitu thrombus . Congenital obstruction is rare. It may be due to a membrane or interruption with azygos continuation(2). In IVC interruption with azygos continuation, the hepatic veins drain directly into the RA and lower limbs venous drainage is via the azygos system. In such a situation, the alternative route is either hepatic or transjugular approach. Successful deployment of Amplatz device via the transhepatic route was reported(3). But, this approach could cause hepatic injury. Transjugular approach is a superior alternative because it is safer. There are a few case reports of transjugular ASD device deployment. In two reports(4,5), femoral approach was precluded because of acquired IVC obstruction. Marco Papa et al reported three cases of ASD Device deployment through right jugular route in a series of 142 ASD or patent foramen ovale percutaneous closures(6). In those 3 cases , jugular deployment was necessitated by IVC interruption in one and unsuccessful femoral approach due to deficient rims in the other two cases. In all the above reports, the size of the device ranged between 15mm 22mm whereas in our case a 30mm ASD device was successfully deployed through transjugular approach. Entire procedure in the present case was done under fluroscopic and transthoracic echo guidance, whereas TEE was used in previous case reports. We have done a large number of cases under TTE guidance . In our experience TTE guidance is quite reliable. We especially ensure the position of the device in apical 4& 5 chamber & basal short axis views . 6

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As mentioned above, the positioning of the delivery sheath in suitable position in LA may be difficult. Even crossing the defect from above has to be done in a different way from below. In the previous case reports smaller devices were deployed compared to our case where 30mm ASD device was required. The large size of the device in our case added to the difficulty in positioning the assembly in LUPV and deployment of the device. So, temptation to position the delivery sheath in upper pulmonary vein should be resisted as the sheath cannot support device assembly due to U shaped bend of the sheath and the sheath will prolapse into RA. It was suggested previously that use of either heat-shaped or pre shaped introducer might help over coming this problem(4). Conversely, if the delivery sheath is oriented to face the LLPV, the released LA disc may obstruct the LV inflow. It may be prudent to orientate the delivery sheath towards LA free wall as done in the present case, especially if the rims are good. If one of the rims, especially anterosuperior, is extremely deficient/thin, the femoral approach may not be successful because of anchorage problem. It is important to realise that oversizing the device will not circumvent this difficulty. In this situation, a jugular approach may be successful because it affords a different orientation of the LA disc from the femoral approach and increases the chances of anchorage. Whether to release the LA disc in the LV inflow as suggested by Marco Papa et al or in the LA orienting the disc towards the LA free wall. To conclude, transjugular ASD device deployment can be done successfully when transfemoral route is not possible..

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REFERENCES 1.King TD, Mills Nl. Nonoperative closure of atrial septal defects.Surgery 1947;75:383-388. 2.Blanchard DG, Sobel JL, Hope J, Raisinghani A, Keramati S, DeMari An. Infrahepatic interruption of the inferior vena cava with azygos continuation: a potential mimicker of aortic pathology. J Am Soc Echocardiogr. 1998;11: 1078-1083. 3.Saliba Z, Boudjemline Y, Acar P, Hausse A, Sidi D, Bonhoeffer P. Transhepatic closure of a post-fontan hepatic veins to left atrium fenestration in visceral heterotaxia and dextrocardia. J Interv Cardiol. 2002;15:215-217. 4.Thompson Sullebarger j,Dany Sayad,Lowell Gerber .Percutaneous closure ostium secundum atrial septal defect via transjugular approach with the Amplatzer septal occluder after unsuccessful attempt using the CardioSEAL device. Catheterization and cardiovascular interventions .2004;62:262-265. 5.Abdel-Massih T, Boudjemline Y, Agnoletti G, Acar P, Iserin F, Douste-Blazy M-Y et al. Percutaneous closure of an interatrial communication via the internal jugular route with an Amplatz prosthesis. Arch Mal Coeur Vaisseaux. 2002; 95:959-961. 6.Marco Papa, Achille Gaspardone, Garbriele Fragasso, Chiara Camesasca, Andrea Conversano, Fabrizio Tomai et al . Jugular approach for percutaneous closure of atrial septal defect. Ital Heart J .2004; 5 : 466469

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Figure

Figure-1 :IVC gram in lateral view showing right atrium (vertical arrow) and IVC interruption with azygos continuation(arrow head)

Figure

Figure-2: IVC gram in lateral view showing azygos vein draining into superior vena cava.

Figure

Figure-3: Delivery sheath positioned in the LUPV. Note the acute bend(*) on the Sheath

Figure

Figure-4: 12Fr ,60 cm delivery sheath (Shanghai shape memory alloy company limited) positioned in the left lower pulmonary vein.

Figure

Figure-5: RA angiogram showing device in situ

*Certification Form

Certification Form Manuscript title:" percuta eousCf n osureOf ASD Trans g u l a r Via u Dlviceln A Patient With fnterru ted
we herebycertif,' that the work submitted is with the statement "prerequisites publication" in full accordance of for fo, Cardiovascurar Intervention a.1/ Therapeutic Dr.B.srinivas,corresponding .I, author certifythatall listedurihorcqualiS, for authorship iraueconceived, .I planned, performed work and the rlaoingio rt . reportand interpreted the evidence presented.Dr.A.N.patnait ,tiasco- writtenthe reportand reviewed successive versions. theirrevision. and Dr.D.s.rnugi.i Raohas thework, parlicipated

ffifJil.d

in revisions approved finar and the

we certift thatno part of the work described been has published beforeand thatthe work is not underconsideration fbr publication elsewhere.If whenthe runrr..ipt and is accepted publication, agree for we to automatic transfer of the copyrightto the societyand that the manuscript,, its parts, or will not be pubrished ersewhe.e subsequentry anyianguage in withoutthe consent the copyright of notO..r. we haveno conflictof interest to declare in Author'sname D.Seshagiri rao B.Srinivas A..N.Patnaik this regard. Date

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