Author + information
- Hiroyuki Yamamoto, MDa,
- Hiromasa Otake, MD, PhDa,∗ (, )
- Teiji Akagi, MD, PhDb,
- Kensuke Matsumoto, MD, PhDa,
- Soichiro Henmi, MDc,
- Takeshi Inoue, MDc,
- Hiroshi Tanaka, MD, PhDc and
- Ken-ichi Hirata, MD, PhDa
- aDivision of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
- bCardiac Intensive Care Unit, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
- cDivision of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
- ↵∗Address for correspondence:
Dr. Hiromasa Otake, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 6500017, Japan.
A 74-year-old man with progressive breathlessness was diagnosed as having heart failure due to patent ductus arteriosus (PDA) (Figure 1). Percutaneous PDA closure was performed transvenously using a 16-mm Amplatzer Vascular Plug II (St. Jude Medical, St. Paul, Minnesota). His blood pressure was strictly controlled with a continuous injection of nicardipine; the final aortogram confirmed no residual shunt (Figure 2). Fluoroscopic findings, however, showed that the pulmonary retention disc was not completely released compared with the aortic retention disc, suggesting residual mechanical stress on the device in longitudinal direction (Figure 3).
On the following day, the patient suddenly reported severe back pain. Emergent computed tomographic angiography demonstrated type A aortic dissection, extending from the contact site of the aortic retention disc to the aortic wall. Furthermore, computed tomographic angiography revealed that the deformed pulmonary retention disc became as thin as the aortic retention disc, which partially migrated into the PDA (Figure 4). Emergent ascending aortic replacement and stent graft implantation over the PDA were performed. Intraoperative findings confirmed that the dissection indeed initiated from the contact site of the aortic retention disc to the aorta (Figure 5).
Although speculative, potential mechanisms for aortic dissection include mechanical stress at the transition of PDA and aorta with possible vulnerability of the enlarged aortic arch (42 mm). Post-procedural fluoroscopy showed that the Amplatzer Vascular Plug II had dynamic morphological changes with heartbeat, with significant elongation in the diastolic phase followed by shortening in the systolic phase (Figure 3). Emergent computed tomographic angiography and post-operative fluoroscopy showed that the pulmonary retention disc became as thin as the aortic retention disc after aortic dissection onset (Figure 6), supporting our speculation. Appropriate device selection with morphological evaluation after Amplatzer Vascular Plug II implantation might be important, especially in elderly patients with large PDAs.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 24, 2018.
- Accepted October 16, 2018.
- 2019 The Authors