Perforation of an Aortopulmonary Collateral: A Scary Sight in the Lab!

J INVASIVE CARDIOL 2021;33(4):E312-E313. 

Key words: aortopulmonary collaterals, coil embolization, cyanotic congenital heart disease, perforation

A 12-year-old boy with complex cyanotic congenital heart disease with single-ventricle physiology presented to our clinic. The patient was planned for univentricular repair. The preoperative catheterization study showed multiple large aortopulmonary collaterals (APCs) arising from the descending thoracic aorta (DTA) and the left subclavian artery. APC occlusion using thrombotic embolization coils was planned (Figure 1A). During the procedure, there was a perforation of an APC arising from the DTA (Figure 1B), resulting in extensive mediastinal contrast staining (Figure 1C). The perforation occurred because a 3 mm coil was used in an APC that was smaller than 2 mm. As the APC originated from the DTA, the perforation led to contrast staining along the planes of the mediastinum. Although no active contrast spurt was observed, repeated injections to check the status of the leak resulted in a significant staining, causing a large shadow on fluoroscopy. 

We attempted to seal the perforation by prolonged balloon inflation using a 2 x 15 mm monorail coronary balloon advanced over a coronary guidewire (Figure 1D; Video 1). Protamine was given to partially reverse the anticoagulation. The leak was successfully controlled, and coiling of the remaining APCs was done (Figure 1E; Video 1). The patient underwent successful bidirectional Glenn procedure, no mediastinal collection was noted intraoperatively, and the postoperative course was uneventful.

The teaching point from this case is that all APCs do not necessarily need to be occluded and small collaterals can be left alone. When coiling is performed, it is important to appropriately size the coils. Using large coils in a small collateral channel can result in perforation or rupture. If a perforation does occur, it is likely to seal by itself as the coils are thrombotic in nature. However, if the leak is large, options include inserting a coil proximally or using gel foam or polyvinyl alcohol particles for distal embolization. Neither of these options were available in our case; hence, balloon inflation was used as a temporizing maneuver until spontaneous occlusion occurred. APC perforation may appear large and dangerous, but generally does not lead to serious consequences, as the location is extracardiac and extrapulmonary.

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From the Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 1, 2020.

Address for correspondence: Professor H.S. Isser, Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110029, India. Email: drhsisser@gmail.com