Coil Closure of the Large Patent Arterial Duct: Cheap, But How Easy and Effective?

Coil occlusion has become an accepted alternative treatment for small to moderate sized patent ductus arteriosus (PDA). Gianturco coils (Cook Cardiology, Inc., Bloomington, Indiana) are small, coiled spring wires with fabric strands woven into the springs. They are available in standard 0.035´´, 0.038´´ and 0.052´´ sizes. The accurate placement of coils in a PDA may be a challenging and frustrating task to the interventionalist, especially in the large ductus (>= 4 mm). Multiple alternative techniques for coil delivery have been devised to improve the success rate of ductus closure. Some of these techniques include the use of a nitinol snare for controlled and accurate positioning of the coil;1,2 a snare and bioptome combination for better control and release;3 forceps delivery;4 the use of a modified delivery catheter for better control;5 the use of multiple coils for larger PDAs;6–8 and the use of the thicker wire coils, i.e., “0.052-inch”, for closure of larger PDAs.9 Detachable coils have also been developed that allow the coil to be placed and assessed for correct position prior to release.10 Devices have also been developed and evaluated to allow closure of larger PDAs and improved control of delivery. The Gianturco-Grifka vascular occlusion device (Cook Cardiology, Inc.) is a fabric sack into which a long coil is extruded that conforms to the size and shape of the vascular structure and can be used for larger PDAs with improved delivery control.11 However, the use of the Grifka sack is limited to long PDAs (angiographic types C, D and E), which are not the more common types of PDA. The Rashkind occluder and the buttoned device can be used for a variety of PDA sizes and types. However, a significant incidence of initial residual shunts, shunts present at 1-year follow-up, and risk of left pulmonary artery stenosis has prevented their widespread acceptance.12,13 The Rashkind device is essentially nonexistent in clinical practice and the buttoned devices are not widely used at all. The Amplatzer Duct Occluder (ADO; AGA Medical Corporation, Golden Valley, Minnesota) was designed exclusively for PDA occlusion. The initial report has shown excellent success with a complete closure rate of 100% at 1-month follow-up and no complications.14 The ADO device has several advantages over the other available methods of PDA closure. It has a complete closure rate that is as high or is achieved sooner than other methods and has not been noted to have recurrence of shunting. The variety of available device sizes (ranging from 4–14 mm) allows it to be used effectively in cases of large PDAs. The ADO was effectively used to close PDAs up to 12.5 mm in diameter and was used to close all PDA types.15,16 The ADO may be more desirable in adults where calcification of the PDA may be present, which can complicate surgical closure. The transvenous delivery route and the small 5–7 Fr sheath required for delivery limit the risk of vascular compromise. The ability to retrieve and reposition the ADO device prior to its release is an important feature not available with many other transcatheter occlusion methods. This feature provides the comfort and confidence to handle any size or shape PDA during the procedure. In the United States, this device remains under clinical evaluation; however, it is readily available outside the U.S. See Huang et al. on pages 173–177 In this issue of the Journal, Huang et al. report on their experience using the modified 0.052´´ Gianturco coil to close large PDAs (>= 4 mm). They used the 0.052´´ coil in 15 patients. Initially, their approach was from the arterial side; however, due to severe vascular injury of the femoral artery in their third patient, the remainder of patients underwent closure from the transvenous anterograde route using a 7 Fr guiding catheter. The authors were able to successfully close the PDA in 13 of the 15 patients. One patient underwent surgical removal of an embolized coil and ductus ligation and another patient underwent surgical ligation of the ductus due to severe hemolysis. A total of 4 complications occurred in this series (26.7%), including 2 with significant hemolysis. This is a high and unacceptable rate of hemolyis. Therefore, the authors correctly point out the importance of achieving complete closure in the catheterization laboratory using the 0.052´´ coils. In the event of residual shunt prior to the patient leaving the room, the authors recommend repositioning the coils using a balloon-tipped catheter to minimize this complication. They mention that they use echocardiography to detect residual shunt in an effort to minimize the use of fluoroscopy, which was not reported in their data. Therefore, I believe the use of Gianturco coils is still the most common method of closing a ductus. Coils are cheap, readily available and easily achieve complete closure in over 90% of small to moderate PDA. However, for the larger duct, the complication rate and complete closure rate are not as good as one would like. Hence, I believe a strategy of patient selection based on the angiographic diameter and type of the ductus is crucial to the success of the procedure. The use of 0.052´´ coils is effective in a large number of patients. However, I also believe that the availability of the “Amplatzer duct occluder” device in the catheterization laboratory is essential to best manage the large PDA. Although the cost of the Amplatzer device is certainly more than the coil, I still believe that if you factor in the rate of complications, the rate of residual shunt and the anxiety involved on the part of the operator using coils, the use of the Amplatzer device will be a more cost-effective strategy. I would like to see a randomized clinical trial in patients with larger PDAs (>= 4 mm) comparing the use of Gianturco coils with the Amplatzer device with emphasis on the following parameters: rate of complete closure and incidence of residual shunt; complication rate; fluoroscopy time; and the cost of the procedure. At the end, the device with the highest complete closure rate and lowest complication rate would win the respect of the interventional cardiologist.

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