Challenging Closure of a Patent Foramen Ovale via a Superior

*Ravinay Bhindi, MBBS, PhD, FRACP, FESC, §Neil Wilson, MBBS, FRCP, *Oliver J. Ormerod, DM, FRCP
*Ravinay Bhindi, MBBS, PhD, FRACP, FESC, §Neil Wilson, MBBS, FRCP, *Oliver J. Ormerod, DM, FRCP
This case describes the closure of a patent foramen ovale (PFO) via the right internal jugular (IJ) vein in a young patient with an interrupted inferior vena cava (IVC) awaiting liver transplantation.
Case Report. A 25-year-old male with chronic liver failure due to Budd Chiari syndrome had a PFO discovered on contrast echocardiography as part of his transplantation workup. He was subsequently referred by the transplant team for PFO closure prior to liver transplantation to avoid the potential for intraoperative paradoxical embolism.
As the IVC was known to be thrombosed, the right IJ vein was used for vascular access. Following sedation, the right IJ vein was cannulated using a modified Seldinger technique and a 12 Fr sheath was inserted. Routine cardiac imaging options were restricted in this case: intracardiac echocardiography vascular access was limited to the contralateral jugular vein, however, dual-neck vascular catheterization was deemed inappropriate because of the risk of bleeding causing asphyxiation. In addition, transesophageal echocardiography (TEE) was not performed because of esophageal varices, while transthoracic imaging, which was performed, provided poor echocardiographic windows because of anatomic distortion from ascites.

Balloon sizing of the defect (Figure A) performed during the case facilitated fluoroscopic localization of the defect as the heart was rotated by pleural effusions and ascites making interpretation of standard fluoroscopic landmarks difficult. It proved difficult to cross the PFO, and this was finally achieved with a 3.5 left Judkins catheter. Monorail advancement of a Helex delivery system was not technically possible, thus a long 9 Fr Mullins sheath was advanced into the left atrium and a 7 mm Amplatzer atrial septal defect (ASD) device was successfully deployed (Figure B) with a good final result (Figure C).
Percutaneous repair of intracardiac lesions is being increasingly performed, and as such, the operator is likely to be confronted with the prospect of more complex cases. The utilization of the IJ vein to close a PFO has been reported only in a limited number of cases in the literature,1 usually with the assistance of TEE. Although the Amplatzer ASD device is not presently FDA-approved for this indication, this case illustrates a challenging PFO closure performed using a nonconventional vascular access site in a setting further complicated by limited imaging assistance.
1. Sader MA, De Moor M, Pomerantsev E, Palacios IF. Percutaneous transcatheter patent foramen ovale closure using the right internal jugular venous approach. Catheter Cardiovasc Interv 2003;60:536–539.