Use of a Patent Ductus Arteriosus Occluder in the Treatment of a Renal Artery–Inferior Vena Cava Fistula

Article Outline

• Abstract
• Introduction
• Report
• Discussion
• References
• Copyright

Abstract 

We report a case where an 8-mm mushroom patent ductus arteriosus occluder was used in a 59-year-old woman to resolve a renal artery–inferior vena cava fistula that occurred following a right nephrectomy performed 27 years earlier. Complete occlusion of the fistula was achieved. This case highlights the novel use of a PDA occluder and provides evidence that this may be a viable technique for the management of arteriovenous fistulas with similar vessel relationships, anatomical characteristics and occlusion demands as the fistula described in this report.

Keywords: Fistula, Occluder, Renal artery–inferior vena cava fistula, Treatment

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Introduction 

The unique anatomical characteristics involved in renal artery–inferior vena cava fistulas require special consideration of the optimal method selected for their occlusion. Herein we describe the novel use of a patent ductus arteriosus (PDA) occluder to successfully treat a post-nephrectomy renal artery–inferior vena cava fistula rather than surgical closure or use of the Amplatzer vascular plug as previously described.¹, ²

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Report 

A 59-year-old woman, who had her right kidney removed 27 years earlier, was admitted to the hospital for investigation of a 2-month history of chest tightness, upper abdominal discomfort and facial oedema.

On physical examination, a cardiac dullness and systolic bruit were auscultated. Colour echocardiography revealed generalised cardiomegaly, severe tricuspid regurgitation, pulmonary regurgitation and mild pulmonary hypertension and pericardial effusion. Magnetic resonance angiography (MRA) identified a single abnormal communication between the right renal artery and inferior vena cava consistent with a diagnosis of a right renal artery–inferior vena cava fistula.

Occlusion of the fistula with an 8-mm mushroom PDA occluder (SHSMA Corporation, Shanghai, China) was chosen. Under local anaesthesia, two sheaths were placed in the right femoral artery and vein. After heparinisation, a 5F pigtail catheter was inserted through the arterial sheath to perform an abdominal aortogram (Fig. 1). The diameter of the origin of the right renal artery was 7mm. A Judkins catheter was subsequently inserted through the arterial sheath to cannulate the right renal artery, and a 0.035in×10in ultra-smooth guide wire (Boston Scientific, Natick, MA, USA) was threaded into the inferior vena cava. The guide wire was snared via the venous sheath forming a femoral artery fistula–femoral vein circuit. A 6F delivery sheath was inserted over the guide wire and advanced to the abdominal aorta through the fistula. The 8-mm mushroom PDA occluder (Fig. 2A) was placed in the aorta at the level of the right renal artery. The aortic surface of the occluder was released and the occluder was then withdrawn into the origin of the right renal artery. The sheath was retrieved and the occluder was completely released to resolve the fistula (Fig. 3).

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• Figure 1 

  Pre-occlusion abdominal aortogram. The arrow indicates the location of the iatrogenic renal artery–inferior vena cava fistula.

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• Figure 2 

  Illustrations of SHSMA and Amplatzer occluder. (A) The SHSMA occluder used in the present case. (B) The Amplatzer occluder – the shape of the occluder is shown the right-upper panel. A white arrow indicates the fitness of the occluder in the defect on interatrial septum. The illustration was adopted with modification from the website of the U. S. Food and Drug Administration. Available from: http://www.fda.gov/cdrh/mda/docs/p000039.html.

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• Figure 3 

  Post-occlusion abdominal aortogram. The arrow indicates the position of the PDA occluder that was employed to resolve the fistula.

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Discussion 

Renal artery–inferior vena cava fistulas can result in cardiac hypertrophy and dilation and congestive heart failure. The ideal management of this condition remains to be determined; however, several treatment options have been considered, including surgical ligation,¹ steel coil³ or detachable balloon embolisation,⁴ covered stents⁵ or occluders.²

In this case, a minimally invasive technique was desired, therefore surgical ligation was not considered. In order to occlude the 7-mm diameter origin of the right renal artery without the risk of migration or dislodgement of an implanted device and to minimise the potential for residual flow that can occur with device movement or balloon deflation, the mushroom-shaped PDA occluder was selected. To ensure that a secure embolisation was achieved, the PDA occluder was fully expended in the abdominal aorta and then the stem (8mm diameter) of the occluder was drawn into the 7mm origin of the right renal artery stump until the occulter disc (10-mm diameter) covered the origin of the right renal artery tightly by the blood pressure in the abdominal aorta. This technique resulted in a tight, secure and permanent embolisation. While this technique may be perceived as more labour-intensive than using alternate percutaneous techniques, the end result is anticipated to have a higher success rate.

The PDA occluder was selected because it was hypothesised to be better able to withstand the high-pressure, mono-directional flow in the fistula pathway than other occluders such as the Amplatzer plug which has been previously used in a similar case.² The Amplatzer plug is a circular grove flanked by two discs and is designed to repair defects of the ventricular/interatrial septum (Fig. 2B). In the case described herein, due to the fact that the residual right renal artery is far longer than the width of the circular grove of the Amplatzer plug and because of the high-pressure, mono-directional flow from the aorta to the inferior vena cava, the concern regarding migration or dislodgement of the Amplatzer plug could not be removed.

This case highlights the novel use of the PDA occluder suggesting that this technique may be a viable alternative in the treatment of arteriovenous fistulas with similar vessel relationships, anatomical characteristics and occlusion demands.

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References 

1. Ozaki K, Kubo , Kubo T, Hanayama N, Hatada K, Shinagawa H, et al. High-output heart failure cased by arteriovenous fistula long after nephrectomy. Heart Vessels. 2005;20:236–238
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2. Taneja M, Metupalle V, Kian Hion T, Bien Soo T, Htoo A. Postnephrectomy fistula between the renal artery stump and inferior vena cava treated with Amplatzer vascular plug: gray-scale and Doppler sonographic findings. J Clin Ultrasound. April 2008;29:10.1002/jcu.20467. Published online
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3. Guo H, You B, Lee JD. Dilated cardiomyopathy caused by a coronary–pulmonary fistula treated successfully with coil embolization. Circ J. 2006;70:1223–1225
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4. Botelberge T, Van Vlierberghe H, Voet D, Defreyne L. Detachable balloon embolization of an arterioportal fistula following liver biopsy in a liver transplant recipient: a case report and review of literature. Cardiovasc Intervent Radiol. 2005;28:832–835
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5. Yilmaz S, Erdoğan A, Lüleci E. Transvenous embolization and stent placement for an internal iliac arteriovenous fistula with central iliac vein occlusion. J Vasc Interv Radiol. 2004;15:399–404
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