Transhepatic Access for Transcatheter ASD Closure in Patients With Interrupted IVC

Abstract

Atrial septal defect (ASD) is typically managed with percutaneous transcatheter closure via femoral venous access. In patients with interrupted inferior vena cava (IVC), however, conventional access is not feasible. Although the transhepatic approach has been described, it is less frequently utilized. We report 2 patients with secundum ASD and interrupted IVC who underwent successful device closure through transhepatic venous access. Complete closure was obtained in both cases. These cases highlight the feasibility of transhepatic access for ASD closure when femoral access is not possible. Ultrasound guidance and coil embolization of the hepatic tract appear to be important strategies for reducing complications, particularly hemorrhage. One of our patients developed hemoperitoneum requiring emergent laparotomy, whereas the second patient had an uneventful recovery. Transhepatic access provides a valuable alternative route for percutaneous ASD closure in patients with interrupted IVC, and it can expand therapeutic options for structurally complex cases.

Visual Summary

Secundum atrial septal defect (ASD) is among the most prevalent forms of congenital heart disease, with an estimated incidence of approximately 164 per 100,000 live births. The condition has been reported to occur more frequently in premature infants. Most affected children remain asymptomatic during infancy, and spontaneous closure is commonly observed in small defects.¹

Percutaneous device closure has become the preferred treatment for patients with secundum-type ASDs due to its high procedural success rates and low complication rates across various occluder devices, supporting its safety and efficacy.²

During the procedure, the sheath and closure device are typically advanced through the femoral vein into the inferior vena cava (IVC), and then into the right atrium (RA).

The IVC is a large retroperitoneal vessel responsible for transporting deoxygenated blood from the lower extremities, pelvis, and abdominal organs to the RA of the heart. The azygos venous system, located paravertebrally within the posterior thoracic region, serves as an important collateral pathway between the superior vena cava (SVC) and the IVC. It is composed of the azygos, hemiazygos, accessory hemiazygos, and left superior intercostal veins, which typically form an H-shaped anatomical configuration.³

Interruption of the IVC is an uncommon congenital anomaly in which venous return from the lower body is rerouted through the azygos or hemiazygos venous pathways. The term “interruption” refers both to complete agenesis of the IVC and to anomalous variations in its course.⁴

These anatomical variants are usually asymptomatic when accompanied by a well-developed azygos or hemiazygos continuation. However, in some cases, they may manifest clinically with recurrent deep vein thrombosis of the lower extremities, limb swelling, pain, venous varicosities, abdominal discomfort, and in rare instances, hematochezia. In asymptomatic individuals, the condition is most often identified incidentally during early or middle adulthood.⁵

In such instances, this standard access route for ASD closure may not be feasible, and alternative access routes—such as transjugular or transhepatic—may be considered.

Although the transhepatic approach is well described in the literature, it is less commonly performed.

In this paper, we report 2 cases of successful ASD closure via transhepatic access in patients with interrupted IVC, highlighting procedural details and associated complications.

Case 1

A 15-year-old female with occasional palpitations underwent cardiac evaluation. Transthoracic echocardiography revealed a secundum ASD with significant left-to-right shunting, and she was referred to our center for further assessment and potential closure.

A 12-lead electrocardiogram showed a normal sinus rhythm with incomplete right bundle branch block and T-wave inversion in leads V₂ and V₃. Chest x-ray revealed signs of right ventricular enlargement and pulmonary overcirculation.

Transesophageal echocardiography (TEE) confirmed a small secundum ASD (0.7 × 1.3 cm) with a Qp/Qs ratio of 1.6 and sufficient rims (anteroinferior 1.3 cm, posterosuperior 0.7 cm, anterosuperior 0.8 cm, posteroinferior 0.8 cm, IVC rim 0.8 cm, and SVC rim 1.5 cm). The patient had moderate right ventricular enlargement with mild systolic dysfunction.

She was scheduled for transcatheter ASD closure. On the day of the procedure, femoral access was attempted; however, the catheter could not be advanced inside the IVC. Interrupted IVC was suspected and later confirmed by fluoroscopic image of catheter position and contrast injection. The procedure was canceled and rescheduled for ASD closure via transhepatic access.

Case 2

A 14-year-old male was referred for cardiac evaluation after a grade II/VI systolic murmur was noted during auscultation.

Transthoracic echocardiography revealed a secundum ASD, and TEE was performed for further evaluation. A moderate-sized ASD (1.6 × 1.3 cm) with a Qp/Qs ratio of 1.65 and adequate rims (anterosuperior: 0.3 cm, posteroinferior: 1.8 cm, anteroinferior: 1.4 cm, posterosuperior: 1.5 cm, IVC rim: 2.1 cm, SVC rim: 0.8 cm) was identified. The right ventricle was severely enlarged, with preserved systolic function.

During echocardiographic imaging, the IVC appeared collapsed, and its continuity could not be assessed, raising suspicion of IVC interruption. Right-heart catheterization confirmed the interrupted IVC, and the patient was scheduled for transhepatic ASD closure.

Procedure

Preprocedural considerations

To successfully implement this technique, a detailed preprocedural assessment is essential before performing transhepatic cardiac catheterization. This includes obtaining a thorough medical history to rule out underlying hepatic disease and to review the patient's current and past use of anticoagulant and antiplatelet agents. It is generally advisable to avoid antithrombin therapy prior to the procedure, whereas discontinuation of antiplatelet medication is not always necessary, as these agents may facilitate tract closure following sheath removal. When clinically appropriate, laboratory studies to evaluate coagulation parameters and liver function should be performed.

Accurate knowledge of liver anatomy is particularly important in patients with complex congenital heart disease or suspected heterotaxy syndromes, in whom hepatic positioning may vary. A history suggesting elevated central venous pressure—such as in patients with Fontan circulation or right-sided cardiac lesions—should be recognized and considered in procedural planning and postoperative management, although it does not constitute a contraindication to the transhepatic approach. In these cases, we recommend using preprocedural computed tomography venography for better visualization of the anatomy and accurate planning.

Steps for transhepatic access

The procedure can be conducted under either general anesthesia or conscious sedation. When conscious sedation is chosen, as we did, adequate local anesthesia of both the skin and the deeper hepatic parenchyma is mandatory, as needle entry and sheath advancement can be painful. Additional local anesthetic may be required before introducing larger sheaths. Continuous monitoring of blood pressure is essential throughout the procedure and can be achieved using an indwelling arterial line.

For advancing a 9-F delivery sheath via transhepatic access, the minimum hepatic vein diameter is generally considered ≥5-6 mm when measured by ultrasound.

For venous access, a long 21- or 22-gauge needle is typically used. A 0.018-inch floppy-tip guidewire (Abbott) is introduced through the needle once access to the vessel is confirmed. A transitional or coaxial sheath that allows stepwise upsizing of the wire facilitates insertion of the required dilator and 9-F delivery sheath.

• •Entry point: Under fluoroscopic guidance with both anteroposterior and lateral projections, the needle is inserted in the mid-to-anterior axillary line (best location guided by ultrasound) just below the costal margin.
• •Trajectory: Directed superiorly, posteriorly, and medially toward the patient's left shoulder pointing toward hepatic hilum. A subtle “pop” sensation may be felt upon entry into a hepatic vein. After removal of the obturator, a contrast-filled syringe is attached to the needle. Gentle aspiration is performed while slowly withdrawing the needle until blood is obtained, at which point the needle is stabilized.
• •Imaging confirmation: A small contrast injection is then made under fluoroscopy to outline the hepatic venous anatomy. Distinction between hepatic and portal veins is achieved by observing the direction of blood flow. Once access to the right hepatic vein was successfully obtained, the syringe is removed, and the 0.018-inch guidewire is advanced under fluoroscopic visualization. The wire should pass smoothly into the RA and, when feasible, into the SVC or pulmonary vein in the presence of an ASD (Figure 1, Videos 1 and 2).

Figure 1.

Establishing Transhepatic Access When Femoral Route is Unavailable

(Left) Fluoroscopic image obtained during transfemoral access for transcatheter atrial septal defect (ASD) closure demonstrates interruption of the inferior vena cava (IVC) with azygos continuation. (Right) Fluoroscopic image demonstrating contrast injection into the hepatic vein under real-time ultrasound guidance during transhepatic access for transcatheter atrial septal defect (ASD) closure. The contrast opacifies the hepatic venous branches, confirming correct intravascular positioning of the needle prior to sheath insertion. This step ensures safe establishment of transhepatic venous access in the setting of interrupted inferior vena cava, providing a secure route for subsequent catheter advancement toward the right atrium.

Ultrasound imaging may be used as an adjunct to fluoroscopy or as a standalone modality to identify the hepatic vein and facilitate safe transhepatic access. In our cases, we used ultrasound guidance for both patients to better visualize hepatic veins, and we recommend doing so for all patients to reduce unsuccessful punctures leading to hemorrhagic complications.

Steps for ASD closure

A 0.035-inch hydrophilic guidewire (Terumo Glidewire, Terumo) was gently advanced into the RA, then across the septal defect into the left atrial appendage (LAA). The guidewire was subsequently exchanged for a superstiff wire (Amplatz Super Stiff guidewire, Boston Scientific), over which the delivery sheath was advanced into the LAA and the left lower pulmonary vein.

A sizing balloon (Amplatzer sizing balloon, Abbott) was then inflated to determine the appropriate size for the closure device (Figure 2). Initially, the left atrial (LA) disc of the device (Figulla Flex II, Occlutech) was deployed while the catheter remained in the LA. The catheter and device were then withdrawn until the LA disc aligned parallel to the LA aspect of the interatrial septum. Following this, the RA disc was fully deployed (Figure 3, Videos 3 and 4).

Figure 2.

Fluoroscopic Frame Demonstrating Balloon Sizing of the Atrial Septal Defect During Transhepatic Transcatheter Closure

A compliant sizing balloon (measured diameter: 18.28 mm) is positioned across the interatrial septum under fluoroscopic guidance. The balloon is gradually inflated until the waist formation is observed, indicating occlusion of the defect and enabling accurate measurement of the stretched atrial septal defect diameter. The sizing catheter and balloon were advanced through the transhepatic sheath into the right atrium, confirming optimal position and defect dimension assessment prior to device selection.

Figure 3.

Fluoroscopic Images Demonstrating Deployment of the Atrial Septal Defect Occluder Device

The left panel shows fluoroscopic guidance during controlled release of the device across the interatrial septum, with the left and right atrial discs sequentially deployed and aligned in proper position. The right panel demonstrates the final fluoroscopic frame confirming successful device release and stable positioning without residual shunt or device malalignment. Continuous transesophageal echocardiography monitoring ensured accurate alignment across the septal plane and confirmed complete defect closure prior to release.

Prior to releasing the device from the catheter, proper positioning was confirmed by evaluating all rims using two-dimensional and color Doppler TEE. A push–pull maneuver was performed to verify device stability. After the device was released, no complications were observed—there was no pericardial effusion, no compressive effect on adjacent structures (such as the aortic valve, mitral valve, tricuspid valve, SVC, IVC, or pulmonary veins), and no residual leakage was detected.

Postprocedural hemostasis

The necessity of closing the transhepatic tract before sheath removal remains a matter of debate. Some operators recommend closure using coils or tissue adhesive agents such as glue to reduce the risk of retroperitoneal bleeding or hepatic hematoma. Closure is generally considered in patients on antiplatelet therapy, those requiring large-caliber sheaths, younger patients, or individuals with elevated RA pressures.

Regardless of whether tract closure is performed, meticulous attention to hemostasis at the puncture site is mandatory following sheath removal. The absence of external bleeding does not necessarily indicate adequate hemostasis within the hepatic parenchyma. Therefore, firm manual pressure should be applied to the entry site for a minimum of 10 minutes, even if superficial bleeding has ceased earlier. Continuous observation during this period includes monitoring vital signs and assessing for abdominal discomfort every 5-10 minutes, with point-of-care ultrasound used as needed to screen for free intraperitoneal fluid.⁶

In our cases, at the end of the procedure, the hepatic tract was embolized with a 0.035-inch stainless steel embolization coil (Cook Medical), and hemostasis was achieved using N-butyl-2-cyanoacrylate glue (Histoacryl, B. Braun) and manual pressure for 10 minutes (Figure 4, Videos 5 and 6).

Figure 4.

Fluoroscopic Images Demonstrating Management of the Transhepatic Access Tract Following Completion of Transcatheter Atrial Septal Defect Closure

The left panel shows coil embolization of the hepatic tract performed through the existing sheath to achieve tract closure and prevent postprocedural bleeding. The right panel demonstrates contrast injection into the embolized tract, confirming complete hemostasis with no residual contrast extravasation. This technique ensures secure closure of the transhepatic pathway and minimizes the risk of intraperitoneal bleeding.

Patients were transferred to intensive care unit with vital signs monitoring every 10 minutes. Due to severe abdominal pain in one of them, ultrasonography was performed, which led to diagnosis of hemoperitoneum. This patient required emergent laparotomy. After hemostasis was achieved, the patient was monitored in the intensive care unit for 24 hours. She was discharged 2 days later without further complications during follow-up.

Discussion

When conventional venous access routes are not feasible, alternative techniques such as transhepatic access can be considered. First described in 1989, transhepatic access has since been utilized for various cardiac interventions.

The standard method involves fluoroscopy to access a hepatic vein. A needle is advanced into the liver parenchyma, and contrast is injected during needle withdrawal until a vein is visualized under fluoroscopy.

More recently, some studies have advocated for ultrasound guidance during hepatic vein access. In their limited experience, ultrasound use resulted in fewer complications due to better visualization of the liver and surrounding structures, reducing the number of puncture attempts required.

Potential complications include pneumothorax, hemorrhage, hemobilia, cholangitis, liver abscess, sepsis, and hepatic vein thrombosis.^7,8

Qureshi et al. reported on 124 transhepatic procedures over 12 years, identifying 10 (8%) major adverse events in 8 patients, including 6 bleeding complications (5%) and 4 instances of complete heart block (3%). Major bleeding, especially hemoperitoneum, remains the most concerning complication. In their study, 3 cases of hemoperitoneum occurred, one of which resulted in death.

To mitigate bleeding risks, the use of ultrasound for vein visualization and coil embolization of the tract postprocedure has been recommended. Intensive care monitoring for 12-24 hours postprocedure is also advised.⁹

Quiroz Alfaro et al¹⁰ reported 2 cases of transhepatic LAA closure in which no complications related to the transhepatic approach were observed in their cases. Hemostasis was achieved using a single Amplatzer vascular plug (Abbott) in combination with Gelfoam (Pfizer) in both patients. Similarly, most previously reported cases of LAA closure via the transhepatic route describe the use of a vascular plug together with a hemostatic agent to secure closure of the access site. However, alternative strategies, including combinations of vascular plugs with coils or the application of manual compression, have also been documented.

The transhepatic venous route provided stable access for ASD device delivery in this case. Device advancement through the hepatic vein and IVC was generally smooth; however, compared with the traditional transfemoral approach, several technical nuances merit attention. The transhepatic trajectory creates a more vertical and occasionally less coaxial alignment with the interatrial septum, which may require careful sheath manipulation and torque control to achieve optimal device orientation. In our experience, meticulous fluoroscopic and echocardiographic guidance was essential to ensure appropriate alignment prior to device deployment.

Transhepatic access for ASD closure remains an infrequently used but valuable technique. With each case, we aim to improve our skills and outcomes, minimizing complications and broadening our experience. We hope this approach will become a more routine option for patients with interrupted IVC requiring percutaneous structural heart interventions.

Conclusions

Transhepatic access offers a practical and effective alternative for transcatheter ASD closure in patients with interrupted IVC when conventional femoral access is not possible. Although the technique carries risks—most notably bleeding complications—its feasibility and success in our cases demonstrate that, with ultrasound guidance, careful procedural planning, and postprocedure hepatic tract embolization, this approach can be performed safely. As operator experience grows, transhepatic access may become a more widely adopted option for selected patients requiring percutaneous structural heart interventions.

Visual Summary.

Overview of the Clinical Challenge of Atrial Septal Defect Closure in the Setting of Interrupted Inferior Vena Cava, the Transhepatic Solution Employed, and Associated Procedural Complications

IVC = inferior vena cava, ASD = atrial septal defect.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Take-Home Messages

• •Transhepatic venous access provides a safe and effective alternative route for transcatheter atrial septal defect closure in patients with interrupted inferior vena cava when femoral access is not feasible.
• •Careful procedural planning and growing operator experience are key to optimizing outcomes and expanding the use of the transhepatic approach in complex structural heart interventions.

Appendix

Video 1

Fluoroscopic Image Obtained During Transfemoral Access for Transcatheter Atrial Septal Defect (ASD) Closure Demonstrates Interruption of the Inferior Vena Cava (IVC) With Azygos Continuation

Video 2

Fluoroscopic Image Demonstrating Contrast Injection Into the Hepatic Vein Under Real-Time Ultrasound Guidance During Transhepatic Access for Transcatheter Atrial Septal Defect (ASD) Closure

The contrast opacifies the hepatic venous branches, confirming correct intravascular positioning of the needle prior to sheath insertion.

Video 3

Demonstrates Fluoroscopic Guidance During Controlled Release of the Device Across the Interatrial Septum, With the Left and Right Atrial Discs Sequentially Deployed and Aligned in Proper Position

Video 4

Demonstrates the Final Fluoroscopic Frame Confirming Successful Device Release and Stable Positioning Without Residual Shunt or Device Malalignment

Continuous transesophageal echocardiography monitoring ensured accurate alignment across the septal plane and confirmed complete defect closure prior to release.

Video 5

Coil Embolization of the Hepatic Tract Performed Through the Existing Sheath to Achieve Tract Closure and Prevent Postprocedural Bleeding

Video 6

Injection After Coiling to Ensure Proper Hemostasis

Video Summary of Key Points: Transhepatic ASD Closure

This Video Provides a Brief Overview of the Paper

Highlighting the background, case histories, complications, and clinical implications.