1. Abstract A patient who had transcatheter closure of a large patent ductus arteriosus in early infancy developed aortic coarctation during follow-up. Initially balloon angioplasty & subsequently stent implantation have successfully relieved the aortic obstruction. Avoidance of use of large devices in small babies and modification of current devices so that they may not cause aortic obstruction may result in better outcomes. Once aortic obstruction develops, transcatheter management is useful in relieving the obstruction. Development of Aortic Coarctation Following Device Closure of Patent Ductus Arteriosus Arpan R. Doshi, M.D., PGY5, P. Syamasundar Rao, M.D. Division of Pediatric Cardiology, University of Texas Medical School at Houston Discussion Figure 1: Selected cineangiographic frames in straight lateral views prior to (A) and following (B) 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. Introduction Case Report A 5-year-old, 16.3 kg female with Trisomy 21 was seen in outpatient clinic at our institution. She had history of a large PDA which was closed with GGVOD at 4 months of age at another institution. Following closure of the PDA with GGVOD she was reported to have very mild gradient in the isthmus region of the descending aorta which was deemed clinically insignificant at that time. During our evaluation at age six years (weight -18.9 kg; 25 th percentile) she was noted to have blood pressure gradient of 20 mmHg between upper and lower extremities, a grade 2/6 ejection systolic murmur in the left inter-scapular area and mild brachial-femoral pulse delay. Echocardiogram showed peak instantaneous gradient of 44 mmHg across the descending aortic narrowing. Cardiac catheterization revealed a peak-to- peak systolic pressure gradient of 20 mmHg suggesting coarctation (Table). Angiogram showed narrowest aortic segment of 4 mm. In lateral cineangiographic view, there was clear-cut encroachment of the aortic lumen by the GGVOD coils. Based on these data, an 8 mm diameter, 2 cm long Tyshak II balloon catheter (NuMed, Hopkinton, NY) was used for angioplasty; three balloon inflations were performed. Repeat angiogram after balloon angioplasty showed mild angiographic improvement with a residual gradient of 10 mmHg across the site of the narrowing (Table). At the age of 12 years she was noted to have peak instantaneous gradient of 60 mmHg across the coarctation with diastolic extension of Doppler flow. At that time cardiac catheterization showed a peak to peak systolic gradient of 30 mmHg across the site of GGVOD coils. The narrowest aortic segment at the level of GGVOD measured 3.5 mm. The GGVOD device was again noted to protrude into the aorta (Figure 1A). Based on these data a 27 mm–long Palmaz- Genesis stent (Johnson & Johnson, Miami, FL) mounted over 6 mm x 2 cm / 12 mm x 3 cm balloon in balloon (BIB) catheter (Figure 2) was implanted across the narrowed aortic segment and the isthmus with resultant improvement (Figure 1B). Care was taken to avoid stenting the origin of left subclavian artery. There was less than 5 mmHg residual gradient across the stent at the conclusion of the procedure. Follow-up 1 day and 1, 6, 24, 36 and 60 months after the procedure revealed normal blood pressures and no arm-leg blood pressure gradient and no echocardiographic evidence of recoarctation (Table). Conclusions 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. 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. References 1. Grifka RG (2004) Transcatheter closure of the patent ductus arteriosus. Catheter Cardiovasc Interv 61: 554-570 2. Rao PS (2001) Summary and comparison of patent ductus arteriosus closure devices. Curr Interv Cardiol Rep 3: 268- 274 3. Ing FF, Mullins CE, Wolfe SB, Grifka RG (1998) Relief of factitious coarctation following occlusion of large patent ductus arteriosus with Gianturco-Grifka vascular occluder. Cathet Cardiovasc Diagn 45:409-412. 4. Rao PS (2011) Percutaneous closure of patent ductus arteriosus--current status. J Invasive Cardiol 23: 517-520 2013 Texas Pediatric Society Electronic Poster Contest Intervention Phase & Duration Doppler Gradient (mmHg) Cath Gradient (mmHg) Arm-Leg BP Gradient (mmHg) AngioplastyPre4420 Post-10- Follow-up1 Day36-- 2 Months20-21 15 Months40-27 4 Years42-- 5 Years60-47 StentPre603047 Post-5- Follow-up1 Day30-0 1 Month20-0 6 Months25-0 24 Months20 0 36 Months16-0 60 Months16-0 Table Our patient had closure of PDA with GGVOD in early infancy. Although 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. It is not clear whether, what was considered insignificant gradient developed into full-fledged coarctation later or if encroachment of the aortic lumen by the GGVOD device components (Figure 1A) caused this problem. Or, it may be a combination of the above. Given the significant protrusion of the device components into the aortic lumen (Figure 1A), we may have to conclude that the bulky device is responsible for the development of coarctation in our patient. In the presence of both PDA and aortic coarctation, it is generally recommended that both are dealt with either surgery or catheter intervention that can address both the issues. However, in some cases, the coarctation gradient may be fictitious secondary to increased flow across the aortic isthmus [3]. If the coarctation is fictitious, the gradient will be abolished by test occlusion of the ductus and surgery avoided [4]. Figure 2: Selected cineangiographic frames in straight lateral view demonstrating stent implantation; the unexpanded stent (St) across the obstructed site is seen in A with the inner balloon (IB) inflated in B and the outer balloon (OB) inflated in C. Following deflation and removal of the outer balloon (D), the stent is faintly seen, the outer edges are marked with arrows. Table: Immediate and follow-up data following transcatheter intervention Figures Percutaneous occlusion of patent ductus arteriosus (PDA) is well described in literature and is currently widely used in clinical practice. It has been found to be safe and effective method to close PDA [1,2]. We report a patient who had percutaneous transcatheter closure of large PDA at 4 months of age at another institution using Gianturco-Grifka Vascular Occlude Device (GGVOD). She progressively developed coarctation of the aorta. Patient initially underwent balloon angioplasty of coarctation at age 6 years and stent therapy at the age of 12 years with excellent results. This case illustrates risk for development of coarctation with transcatheter PDA closure, mainly with older devices such as GGVOD. AB GGVOD DAo Sh Stent LSA