. 2024 Aug 24;3(10):101211. doi: 10.1016/j.jacadv.2024.101211

Table 5.

Device-Related Complications

Complications	How to Avoid	How to Manage
Device embolization	• Accurate assessment of the PDA dimensions (last-minute TTE (prior to instrumentation) ± angiography. • Appropriate device selection and sizing. • Appropriate device positioning (intraductally in <2 kg infants). • Comprehensive TTE before device release, ruling out any peri-device residual shunt.	• Administer heparin for ACT >200 s. • Get ready for blood transfusion in the event of excessive blood loss due to catheter exchange. • Select a 4F diagnostic catheter for snaring the device, along with a suitable retrieval sheath placed in the MPA (otherwise in the RV or RA). • consider gently unguarded device retrieval if the sheath cannot be safely advanced into the MPA. • In case of aortic embolization, consider device retrieval via the PDA, via a carotid approach or surgically. • Onsite surgeon. Requested materials Retrieval sheath: 4-F or 5-F Cook Flexor Ansel guiding sheath with check-flo hemostatis valve (the 4-F TorqVue LP catheter cannot be used as a retrieval sheath). • Diagnostic catheter for accessing RPA: 4-F Judkins Right 2.0 or 2.5. • Diagnostic catheter for accessing LPA: 3.3-F Mongoose JB1 or JR2. • Snares: 3.2-F Merit Ensnare or 5 mm Amplatz Gooseneck snare.
Device protrusion and aortic and LPA obstruction	• Double check any pre-existing LPA stenosis or aortic coarctation before PDA instrumentation. • Appropriate device length selection (2 mm length in infants <1 kg, 4 mm length only if ductal length >12 mm). • Appropriate device positioning (intraductally in <2 kg infants). • Use the esophageal temperature probe as a fluoroscopic landmark of the aortic isthmus in infants <2 kg. • Consider deploying the aortic disc within the PDA rather than in the DAo to avoid protrusion of its superior edge in the aortic lumen.	• Refer to management algorithm (Figure 4)

Complications

How to Avoid

How to Manage

Device embolization

•
Accurate assessment of the PDA dimensions (last-minute TTE (prior to instrumentation) ± angiography.
•
Appropriate device selection and sizing.
•
Appropriate device positioning (intraductally in <2 kg infants).
•
Comprehensive TTE before device release, ruling out any peri-device residual shunt.

•
Administer heparin for ACT >200 s.
•
Get ready for blood transfusion in the event of excessive blood loss due to catheter exchange.
•
Select a 4F diagnostic catheter for snaring the device, along with a suitable retrieval sheath placed in the MPA (otherwise in the RV or RA).
•
consider gently unguarded device retrieval if the sheath cannot be safely advanced into the MPA.
•
In case of aortic embolization, consider device retrieval via the PDA, via a carotid approach or surgically.
•
Onsite surgeon.

Requested materials
Retrieval sheath: 4-F or 5-F Cook Flexor Ansel guiding sheath with check-flo hemostatis valve (the 4-F TorqVue LP catheter cannot be used as a retrieval sheath).

•
Diagnostic catheter for accessing RPA: 4-F Judkins Right 2.0 or 2.5.
•
Diagnostic catheter for accessing LPA: 3.3-F Mongoose JB1 or JR2.
•
Snares: 3.2-F Merit Ensnare or 5 mm Amplatz Gooseneck snare.

Device protrusion and aortic and LPA obstruction

•
Double check any pre-existing LPA stenosis or aortic coarctation before PDA instrumentation.
•
Appropriate device length selection (2 mm length in infants <1 kg, 4 mm length only if ductal length >12 mm).
•
Appropriate device positioning (intraductally in <2 kg infants).
•
Use the esophageal temperature probe as a fluoroscopic landmark of the aortic isthmus in infants <2 kg.
•
Consider deploying the aortic disc within the PDA rather than in the DAo to avoid protrusion of its superior edge in the aortic lumen.

•
Refer to management algorithm (Figure 4)

Adapted from Sathanandam et al.⁶

ACT = activated coagulation time; DAo = descending aorta; LPA = left pulmonary artery; MPA = main pulmonary artery; PDA = patent ductus arteriosus; RA = right atrium; RPA = right pulmonary artery; RV = right ventricle; TTE = transthoracic echocardiography.