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Migration of an AMPLATZER Atrial Septal Occluder to the Abdominal Aorta
Migration of an AMPLATZER Atrial Septal Occluder to the Abdominal Aorta Emanuele Ferrero, MDa,*, Michelangelo Ferri, MDa, Andrea Viazzo, MDa, Federico Beqaraj, MDb, Lorenzo Gibello, MDa, Giuseppe Berardi, MDa, Davide Santovito, MDa, and Franco Nessi, MDa Percutaneous closure of an atrial septal defect has been increasingly used, and complications have been rare. We report the case of a 63-year-old man who had undergone endovascular closure of a secundum atrial septal defect months earlier. The occluder was later found in the abdominal aorta. Ó 2013 Elsevier Inc. All rights reserved. (Am J Cardiol 2013;112:612e613)
a
Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy; and bCardiology Interventional Unit, Maria Vittoria Hospital, Turin, Italy. Manuscript received March 24, 2013; revised manuscript received and accepted April 8, 2013. See page 613 for disclosure information. *Corresponding author: Tel: (þ39) 11-508-2605; fax: (þ39) 11-5082606. E-mail address: [email protected] (E. Ferrero).
Case Report In December 2012, a 63-year-old man was referred with acute right leg ischemia due to migration of the atrial septal occluder into the right external iliac artery. He had arterial hypertension and had experienced a cryptogenic stroke on October 6, 2012 that was successfully treated with thrombolysis therapy. After that episode, transthoracic echocardiography revealed a secundum atrial septal defect (ASD) with a maximum diameter of 11.5 mm and a pulmonary flow to systemic flow ratio of about 1.4. On October 23, 2012, a 12-mm AMPLATZER septal occluder (ASO) device (St. Jude Medical, North Plymouth, Minnesota) was placed through left percutaneous femoral vein access, with the patient under local anesthesia. The patient was discharged on the second day after the procedure in good condition. The first transthoracic echocardiographic follow-up study showed ASD patency with migration of the ASO. Three days after the transthoracic echocardiographic scan, the patient underwent catheterization, which demonstrated the presence of the ASO in the abdominal
aorta. Several unsuccessful attempts were performed to capture and remove the ASO using an AMPLATZER gooseneck snare kit. It was only possible to move the ASO as far as the right external iliac artery (Figure 1). Because of the impossibility of ASO endovascular removal and the onset of right limb ischemia, the patient was sent to our center. After a duplex scan confirmed the presence of the ASO in the right external iliac artery, the ASO was surgically removed, with restoration of the normal blood flow. The patient was discharged on the fourth postoperative day in good general condition. Discussion Of all the possible complications, device embolization is 1 of the most common, with an incidence of 0.4% to 1.1%.1e5 ASO dislodgement can occur if a size discrepancy in the defect or excess space is present between the ASD and ASO.1,4 Several reasons can explain this discrepancy. First, ASDs rarely have a perfect circular shape; therefore, it could be difficult to accurately measure the largest diameter of the defect. Second, the flexibility and redundancy of the tissue surrounding the defect could result in a larger defect when the defect itself is stretched with the balloon and in the presence of a floppy rim.4e6 Percutaneous foreign body retrieval is a wellaccepted technique to remove migrated devices, because it obviates major cardiovascular surgery, with high efficacy and few complications.7,8 In the published data, the most common sites of embolization have been the cardiac chambers, pulmonary artery, and aortic arch.2,4,9e13 Reviewing the
Figure 1. (A) Preoperative fluoroscopic image of the device in the right external iliac artery occluding the whole arterial lumen. (B) Intraoperative image of the removal of the AMPLATZER device. (C) Details of the removed device. 0002-9149/13/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2013.04.031
www.ajconline.org
Case Report/AMPLATZER Atrial Septal Occluder Migration
English language reports, we found only 5 case reports of ASO migration into the abdominal aorta and only 1 into the iliac artery, all without limb ischemia.7,14e18 In 2 cases, after surgical exposure of the common femoral artery, a sheath (18F and 20F, respectively) was positioned close to the ASO device. It was grabbed and pulled partially inside the sheath and then down to the arteriotomy site.7,15 In 1 case, owing to total incorporation of the device, endoluminal retrieval was not possible; thus, the device was surgically removed through a medial laparotomy approach.16 In 2 cases, the ASO device was retrieved from the descending aorta by making a horizontal cut in the ascending aorta.14,17 In another case, the ASO device, which had migrated to the level of the aortic bifurcation, was removed by laparoscopic extraction.18 Our report is the first of a case of the ASO device that had dislocated into abdominal aorta and, after an unsuccessful endovascular attempt, had embolized into the iliac vessel, resulting in the complication of an ischemic limb. Disclosures The authors have no conflicts of interest to disclose. 1. Young HK, Hyuck K, Sung JK, Jeong HK, Won-Sang C, Jin-Ho S, Young-Hyo L. Emergent surgical intervention for embolization of atrial septal defect closure device. Korean J Thorac Cardiovasc Surg 2012;45:320e322. 2. Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD. Percutaneous atrial septal occluder devices and cardiac erosion: a review of the literature. Catheter Cardiovasc Interv 2012;80:157e167. 3. Ussia GP, Abella R, Pome G, Vilchez PO, De Luca F, Frigiola A, Carminati M. Chronic embolization of an atrial septal occluder device: percutaneous or surgical retrieval? A case report. J Cardiovasc Med 2007;8:197e200. 4. Levi DS, Moore JW. Embolization and retrieval of the Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;61:543e547. 5. Ueda H, Yanagi S, Nakamura H, Ueno K, Gatayama R, Asou T, Yasui S. Device closure of atrial septal defect: immediate and mid-term results. Circ J 2012;76:1229e1234. 6. Johansson M, Söderberg B, Eriksson P. Availability of percutaneous closure for an adult population with interatrial shunts. Cardiology 2003;99:85e89.
613
7. Wagdi P, Kunz M. Percutaneous, minimally invasive retrieval of a dislodged and impacted device from the abdominal aorta, four months after closure of an atrial septal defect. Am J Cardiol 2008;102: 1111e1112. 8. Wolf F, Schernthaner RE, Dirisamer A, Schoder M, Funovics M, Kettenbach J, Langenberger H, Stadler A, Loewe C, Lammer J, Cejna M. Endovascular management of lost or misplaced intravascular objects: experiences of 12 years. Cardiovasc Intervent Radiol 2008;31:563e568. 9. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496e502. 10. Guimaraes M, Denton CE, Uflacker R, Schonholz C, Bayne SJ, Hannegan C. Percutaneous retrieval of an Amplatzer septal occluder device that had migrated to the aortic arch. Cardiovasc Intervent Radiol 2012;35:430e433. 11. Lloyd TR, Rao PS, Beekman RH III, Mendelsohn AM, Sideris EB. Atrial septal defect occlusion with the buttoned device (a multi institutional U.S. trial). Am J Cardiol 1994;73:283e291. 12. Grayburn PA, Schwartz B, Anwar A, Hebeler RF Jr. Migration of an Amplatzer septal occluder device for closure of atrial septal defect into the ascending aorta with formation of an aorta-to-right atrial fistula. Am J Cardiol 2005;96:1607e1609. 13. Hsiao JF, Hsu LA, Chang CJ, Wang CL, Ho WJ, Chu PH, Ko YS, Kuo CT. Late migration of a Sideris septal occluder device for closure of atrial septal defect into the left atrium with mitral valve obstruction. Am J Cardiol 2007;99:1479e1480. 14. Wei J, Hsiung MC, Tsai SK, Yin WH, Ou CH, Donmez C, Bicer E, Daly DD, Dumaswala B, Dumaswala K, McKay J, Nanda NC. Atrial septal occluder device embolization to an iliac artery: a case highlighting the utility of three-dimensional transesophageal echocardiography during percutaneous closure. Echocardiography 2012;29: 1128e1131. 15. Zorger N, Steinbauer M, Luchner A. Percutaneous removal of embolized Amplatzer occluder from the abdominal aorta: a different type of belly-button. Eur Heart J 2008;29:1791. 16. Jahrome AKh, Stella PR, Leijdekkers VJ, Guyomi SH, Moll FL. Abdominal aortic embolization of a Figulla atrial septum occluder device, at the level of the celiac axis, after an atrial septal defect closure: hybrid attempt. Vascular 2010;18:59e61. 17. Hu C, Huang S, Xu Z, Huang J. Hybrid treatment of a dislocated atrial septal occluder device at the bifurcation of the left and right common iliac artery. Interact Cardiovasc Thorac Surg 2013;16:701e702. 18. Colacchio G, Sciannelli V, Palena G, Coggia M. Total laparoscopic intra-aortic foreign body retrieval. Eur J Vasc Endovasc Surg 2008;35: 737e738.
a
Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy; and bCardiology Interventional Unit, Maria Vittoria Hospital, Turin, Italy. Manuscript received March 24, 2013; revised manuscript received and accepted April 8, 2013. See page 613 for disclosure information. *Corresponding author: Tel: (þ39) 11-508-2605; fax: (þ39) 11-5082606. E-mail address: [email protected] (E. Ferrero).
Case Report In December 2012, a 63-year-old man was referred with acute right leg ischemia due to migration of the atrial septal occluder into the right external iliac artery. He had arterial hypertension and had experienced a cryptogenic stroke on October 6, 2012 that was successfully treated with thrombolysis therapy. After that episode, transthoracic echocardiography revealed a secundum atrial septal defect (ASD) with a maximum diameter of 11.5 mm and a pulmonary flow to systemic flow ratio of about 1.4. On October 23, 2012, a 12-mm AMPLATZER septal occluder (ASO) device (St. Jude Medical, North Plymouth, Minnesota) was placed through left percutaneous femoral vein access, with the patient under local anesthesia. The patient was discharged on the second day after the procedure in good condition. The first transthoracic echocardiographic follow-up study showed ASD patency with migration of the ASO. Three days after the transthoracic echocardiographic scan, the patient underwent catheterization, which demonstrated the presence of the ASO in the abdominal
aorta. Several unsuccessful attempts were performed to capture and remove the ASO using an AMPLATZER gooseneck snare kit. It was only possible to move the ASO as far as the right external iliac artery (Figure 1). Because of the impossibility of ASO endovascular removal and the onset of right limb ischemia, the patient was sent to our center. After a duplex scan confirmed the presence of the ASO in the right external iliac artery, the ASO was surgically removed, with restoration of the normal blood flow. The patient was discharged on the fourth postoperative day in good general condition. Discussion Of all the possible complications, device embolization is 1 of the most common, with an incidence of 0.4% to 1.1%.1e5 ASO dislodgement can occur if a size discrepancy in the defect or excess space is present between the ASD and ASO.1,4 Several reasons can explain this discrepancy. First, ASDs rarely have a perfect circular shape; therefore, it could be difficult to accurately measure the largest diameter of the defect. Second, the flexibility and redundancy of the tissue surrounding the defect could result in a larger defect when the defect itself is stretched with the balloon and in the presence of a floppy rim.4e6 Percutaneous foreign body retrieval is a wellaccepted technique to remove migrated devices, because it obviates major cardiovascular surgery, with high efficacy and few complications.7,8 In the published data, the most common sites of embolization have been the cardiac chambers, pulmonary artery, and aortic arch.2,4,9e13 Reviewing the
Figure 1. (A) Preoperative fluoroscopic image of the device in the right external iliac artery occluding the whole arterial lumen. (B) Intraoperative image of the removal of the AMPLATZER device. (C) Details of the removed device. 0002-9149/13/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2013.04.031
www.ajconline.org
Case Report/AMPLATZER Atrial Septal Occluder Migration
English language reports, we found only 5 case reports of ASO migration into the abdominal aorta and only 1 into the iliac artery, all without limb ischemia.7,14e18 In 2 cases, after surgical exposure of the common femoral artery, a sheath (18F and 20F, respectively) was positioned close to the ASO device. It was grabbed and pulled partially inside the sheath and then down to the arteriotomy site.7,15 In 1 case, owing to total incorporation of the device, endoluminal retrieval was not possible; thus, the device was surgically removed through a medial laparotomy approach.16 In 2 cases, the ASO device was retrieved from the descending aorta by making a horizontal cut in the ascending aorta.14,17 In another case, the ASO device, which had migrated to the level of the aortic bifurcation, was removed by laparoscopic extraction.18 Our report is the first of a case of the ASO device that had dislocated into abdominal aorta and, after an unsuccessful endovascular attempt, had embolized into the iliac vessel, resulting in the complication of an ischemic limb. Disclosures The authors have no conflicts of interest to disclose. 1. Young HK, Hyuck K, Sung JK, Jeong HK, Won-Sang C, Jin-Ho S, Young-Hyo L. Emergent surgical intervention for embolization of atrial septal defect closure device. Korean J Thorac Cardiovasc Surg 2012;45:320e322. 2. Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD. Percutaneous atrial septal occluder devices and cardiac erosion: a review of the literature. Catheter Cardiovasc Interv 2012;80:157e167. 3. Ussia GP, Abella R, Pome G, Vilchez PO, De Luca F, Frigiola A, Carminati M. Chronic embolization of an atrial septal occluder device: percutaneous or surgical retrieval? A case report. J Cardiovasc Med 2007;8:197e200. 4. Levi DS, Moore JW. Embolization and retrieval of the Amplatzer septal occluder. Catheter Cardiovasc Interv 2004;61:543e547. 5. Ueda H, Yanagi S, Nakamura H, Ueno K, Gatayama R, Asou T, Yasui S. Device closure of atrial septal defect: immediate and mid-term results. Circ J 2012;76:1229e1234. 6. Johansson M, Söderberg B, Eriksson P. Availability of percutaneous closure for an adult population with interatrial shunts. Cardiology 2003;99:85e89.
613
7. Wagdi P, Kunz M. Percutaneous, minimally invasive retrieval of a dislodged and impacted device from the abdominal aorta, four months after closure of an atrial septal defect. Am J Cardiol 2008;102: 1111e1112. 8. Wolf F, Schernthaner RE, Dirisamer A, Schoder M, Funovics M, Kettenbach J, Langenberger H, Stadler A, Loewe C, Lammer J, Cejna M. Endovascular management of lost or misplaced intravascular objects: experiences of 12 years. Cardiovasc Intervent Radiol 2008;31:563e568. 9. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496e502. 10. Guimaraes M, Denton CE, Uflacker R, Schonholz C, Bayne SJ, Hannegan C. Percutaneous retrieval of an Amplatzer septal occluder device that had migrated to the aortic arch. Cardiovasc Intervent Radiol 2012;35:430e433. 11. Lloyd TR, Rao PS, Beekman RH III, Mendelsohn AM, Sideris EB. Atrial septal defect occlusion with the buttoned device (a multi institutional U.S. trial). Am J Cardiol 1994;73:283e291. 12. Grayburn PA, Schwartz B, Anwar A, Hebeler RF Jr. Migration of an Amplatzer septal occluder device for closure of atrial septal defect into the ascending aorta with formation of an aorta-to-right atrial fistula. Am J Cardiol 2005;96:1607e1609. 13. Hsiao JF, Hsu LA, Chang CJ, Wang CL, Ho WJ, Chu PH, Ko YS, Kuo CT. Late migration of a Sideris septal occluder device for closure of atrial septal defect into the left atrium with mitral valve obstruction. Am J Cardiol 2007;99:1479e1480. 14. Wei J, Hsiung MC, Tsai SK, Yin WH, Ou CH, Donmez C, Bicer E, Daly DD, Dumaswala B, Dumaswala K, McKay J, Nanda NC. Atrial septal occluder device embolization to an iliac artery: a case highlighting the utility of three-dimensional transesophageal echocardiography during percutaneous closure. Echocardiography 2012;29: 1128e1131. 15. Zorger N, Steinbauer M, Luchner A. Percutaneous removal of embolized Amplatzer occluder from the abdominal aorta: a different type of belly-button. Eur Heart J 2008;29:1791. 16. Jahrome AKh, Stella PR, Leijdekkers VJ, Guyomi SH, Moll FL. Abdominal aortic embolization of a Figulla atrial septum occluder device, at the level of the celiac axis, after an atrial septal defect closure: hybrid attempt. Vascular 2010;18:59e61. 17. Hu C, Huang S, Xu Z, Huang J. Hybrid treatment of a dislocated atrial septal occluder device at the bifurcation of the left and right common iliac artery. Interact Cardiovasc Thorac Surg 2013;16:701e702. 18. Colacchio G, Sciannelli V, Palena G, Coggia M. Total laparoscopic intra-aortic foreign body retrieval. Eur J Vasc Endovasc Surg 2008;35: 737e738.