Clinical course and management strategies for hemolysis after transcatheter closure of patent arterial ducts

Abstract

Residual flows following transcatheter coil or device closure of the patent ductus arteriosus (PDA) can result in hemolysis. Of 611 patients who underwent transcatheter PDA closure at our institution, 5 patients (age, 6-63 years) developed overt hemolysis (after coil occlusion in 4 and Amplazter device closure in 1). All had ducts > 3 mm and residual flows after the procedure. In one patient, hemolysis occurred 3 months after coil occlusion following a period of uncontrolled hypertension. The occurrence of hemolysis correlated significantly with both age as well as duct size (P < 0.00001). Hemolysis was associated with a fall in hemoglobin of 3-6 g/100 ml (n = 3), jaundice (n = 2), and renal failure (n = 1). Hemolysis subsided spontaneously in one patient and four patients required flow elimination. Deploying additional coils in three patients eliminated residual flows. In one patient (after Amplatzer device closure for 12.5 mm duct with aneurysm), flow persisted after 25 additional coils, transient balloon occlusion, and gel foam instillation. Flow elimination was eventually achieved through thrombin instillation after balloon occlusion of the ampulla. All patients recovered completely and were well on follow-up. Although hemolysis after duct occlusion is rare (0.8% in this series), residual flow at the end of the procedure merits careful monitoring. Aggressive elimination of residual flows is often necessary to control hemolysis.

Transcatheter closure of a 22 mm patent ductus arteriosus with an Amplatzer atrial septal occluder

“…Hemolytic anemia in our patient most likely was due to high-velocity blood flow going through the fine wire mesh of the device placed in the ductus. In contrast to the case we are presenting, most cases described in the literature required repeated closure attempts in order to control the erythrocyte destruction [7]. Closure of the residual shunt was not performed since there was no distinctive leak but rather diffuse blood flow through the nitinol meshwork of the device, making implantation of an additional device or multiple coils virtually impossible.…”

“…Clinically overt hemolysis following transcatheter PDA closure is a rare complication and is related to residual shunt. In general, this is seen with the use of coils and typically occurs at a rate of approximately 0.8% [6,7]. When using the Amplatzer duct occluder, hemolysis is even less common [6].…”

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“…Birçok merkezde aynı seansta PDA, ASD ve VSD kapatılması, pulmoner balon valvuloplasti, duktusa ve pulmoner arter dallarına stent uygulanması işlemi yapılmaktadır (53)(54)(55)(56).…”

Large patent ductus arteriosus: To close or not to close

“…The most common complication is embolization of the device. Other potentially important complications are turbulence to flow in the proximal left pulmonary artery or descending aorta from a protruding device, hemolysis from high-velocity residual shunting,[25] femoral arterial or venous thrombosis related to vascular access, and infection. [26] Stiff wires and sheaths stretching cardiac tissues cause bradycardia and hypotension due to vagal stimulation.…”