Ever Heard of Percutaneous Transvenous Selective Coronary Angiography? Unusual Approach in a Patient with Patent Ductus Arteriosus

Abstract

Arterial access for coronary angiography is usually achieved by the use of direct arterial puncture or, less frequently, by arterial cutdown. We present the case of a 39-year-old woman in whom a patent ductus arteriosus was used to enter the arterial system for left ventriculography, aortography, and selective coronary angiography. To our knowledge, this is the 1st reported case of selective coronary angiography with use of a transvenous approach.

In vivo visualization of the coronary arteries was 1st accomplished by use of nonselective injection of contrast medium into the aortic root. ¹ Later, special catheter configurations and other measures, such as pharmacologic induction of bradycardia or short cardiac arrest (several seconds) and hyperbaric ventilation, were used to improve flow of the injected dye into the coronary arteries. ^2–4 In the late 1950s, Sones and Shirey ⁵ developed a new catheter technique that enabled direct probing of the right and left coronary ostia for selective injection of contrast dye into both coronary arteries. This was a major improvement in diagnostic evaluation of coronary artery disease and was a prerequisite for coronary artery bypass surgery and percutaneous balloon angioplasty, which were introduced during the next 2 decades. Today, selective coronary angiography is most often performed with use of the percutaneous technique through the femoral artery. ⁶ A somewhat unusual approach was used in the patient described herein. The aorta was entered from the femoral vein through a patent ductus arteriosus (PDA), thereby avoiding the arterial trauma associated with a percutaneous arterial approach or with arterial cutdown.

Case Report

A 39-year-old woman was referred to our institution in February 1994 for diagnostic evaluation of a suspected congenital cardiac anomaly. Previously, she had been hospitalized elsewhere with signs and symptoms of severe global heart failure, but she could be restored rapidly with vasodilators, diuretics, sedation, and bedrest.

On physical examination, the patient was found to be slightly overweight, without signs of right or left heart failure. She had clear lungs, no peripheral edema, normal liver size, and normal jugular venous pulse. Her blood pressure was 135/80 mmHg, the pulse rate was normal, and all peripheral pulses were palpable. Cardiac auscultation revealed a harsh systolic murmur that extended well into diastole and was best heard in the 2nd intercostal space at the left sternal border. Here, a systolic thrill could be palpated as well. The point of maximal impulse was displaced into the 6th intercostal space in the anterior axillary line. The electrocardiogram indicated that the patient was in sinus rhythm but had biventricular hypertrophy. Chest radiography showed that the heart was enlarged (cor bovinum), with a prominent pulmonary artery and dilated pulmonary vasculature indicative of an increase in pulmonary blood flow. Echocardiographic and Doppler findings confirmed the clinical diagnosis of PDA with a large left-to-right shunt and pulmonary hypertension.

Cardiac catheterization was performed through the right femoral vein with a 5-F sheath and showed normal right atrial pressure. There was no gradient across the tricuspid and pulmonary valves. The patient's pulmonary arterial pressure was 80/40 mmHg (mean pressure, 60 mmHg). The pulmonary capillary wedge pressure was 12 mmHg. The aorta and the left ventricle were entered with a multipurpose catheter through the PDA. There was no gradient across the aortic valve; the aortic pressure was 115/50 mmHg. The peak systolic pressure gradient across the PDA was 35 mmHg (mean gradient, 16 mmHg). The calculated pulmonary-to-systemic flow ratio was 4:1, the pulmonary arteriolar resistance was 295 dyn · s · cm⁻⁵, and the systemic vascular resistance was 1775 dyn · s · cm⁻⁵. After exchange of the multipurpose catheter for a pigtail catheter, aortography (Fig. 1) and left ventricular angiography (Fig. 2) were performed and showed a markedly dilated, hypertrophied left ventricle with globally reduced function (ejection fraction, 0.40). The mitral and aortic valves were competent. The ascending aorta was mildly dilated, as was the pulmonary artery (visible after being filled with contrast medium through the PDA).

Fig. 1 Aortography in the left lateral view during early injection (top) and in the anteroposterior projection during late injection (bottom). The course of the catheter can be seen as it passes from the inferior vena cava through the right heart, the pulmonary artery, and the patent ductus arteriosus.

Fig. 2 Left ventricular angiography (anteroposterior view)

Selective coronary arteriography was also performed transvenously and through the PDA with the multipurpose catheter. An indwelling, pre-shaped, extra-stiff 0.035-inch guidewire increased maneuverability and torque control for catheter placement in the left and right coronary ostia. The left and the right coronary arteries were free of coronary artery disease (Figs. 3 and 4); the right one divided early into a large right ventricular branch and another that continued in the coronary sulcus and ended as the right posterior descending branch. After catheter and sheath removal, a mild compression dressing was applied. The patient was allowed to get up and walk after 1 hour of bed rest. The size of the PDA was considered too large for nonsurgical correction; therefore, the patient was sent to surgery for closure of the defect. Postoperatively, she had an uneventful recovery. When last seen in February 2000, the patient was doing fine. Physical examination revealed normal auscultatory findings, and the heart size was normal on echocardiography.

Fig. 3 Selective coronary arteriogram of the left coronary artery. The multipurpose catheter has been advanced from the inferior vena cava through the right heart, the pulmonary artery, and the patent ductus arteriosus, into the ascending aorta; the tip is in the left coronary ostium.

Fig. 4 Selective coronary arteriogram of the right coronary artery as described for the left coronary artery in Figure 3, but with the tip directed into the right coronary ostium.

Discussion

In addition to the standard techniques of selective coronary arteriography that use the femoral or the brachial artery approach, there are few ways to visualize the coronary arteries. Occasionally, if the coronary ostium cannot be reached with the catheter tip for selective dye injection, aortic root injection may be necessary. Rarely, the usual femoral and brachial approaches are impossible because of extreme kinking or arterial occlusive disease, in which case the axillary artery may provide the only peripheral access. During cardiac surgery, of course, it is possible to obtain a coronary arteriogram by direct cannulation of the vessels.

The case presented herein is, to our knowledge, the 1st reported case of selective coronary arteriography by use of the percutaneous transvenous approach. In our patient, we were able to use the PDA to enter the systemic arterial circulation, thus avoiding the need for arterial puncture or cutdown and the associated inconveniences (for example, compressive dressing after arterial puncture; surgical wound in case of cutdown) and risks. Using the PDA reduced maneuverability somewhat, because in order to reach the aortic root, the catheter had to make a sharper turn when entering the aorta through the ductus. Better torque control was achieved by use of the indwelling, preshaped, extra-stiff guidewire.

Most patients with a PDA are diagnosed at an age when coronary artery disease is of no concern. However, since our patient was 39 years old, and considering that cigarette-smoking, use of birth control pills, and mild obesity were present as coronary risk factors, we decided to exclude the possibility of coronary artery disease angiographically before sending her to cardiac surgery.

We conclude that, if a persistent patent ductus arteriosus can be used to enter the aorta from the venous system through the right heart, selective coronary arteriography can be performed without the risk of arterial cutdown or percutaneous arterial puncture.