first case report of patent ductus arteriosus occlusion with titanium endoclip … · 2018. 1....

JBCA – Jornal Brasileiro de Ciência Animal 2015 8 (16): 638-647 / VETERINARY MEDICINE

638

First case report of patent ductus arteriosus occlusion with titanium

endoclip in a cat

During embryogenesis period, the ductus arteriosus originates from the

sixth left aortic arch, acting as a vascular connection between the

pulmonary artery and the descending aorta. After birth, the functional

ductus arteriosus persistence characterizes the anomaly Persistent

Ductus Arteriosus (PDA), which is an unusual condition in cats. At first,

as a result of this anomaly, volume overload is observed in the left atrium

and ventricle, which according to the chronicity of the disease and the

duct diameter, can impair lung function and even reverse the feeling of

blood flow through the shunt.

Case summary: A mongrel female feline was referred for the surgical

sector of the Animal Experimentation Unit at UENF, presenting

diagnosis of PDA. During the clinical examination the mucous

membranes were normal colored, heart rate considered normal, but with

the presence of systolic murmur III / VI, more audible in the left

hemithorax region. The surgical procedure was performed by

thoracotomy in the fourth intercostal space, identifying the PDA and

performing the occlusion of the duct with vascular titanium clip.

Relevance and novel information: The present study describes the first

case report of a vascular titanium clip occlusion in PDA, which is an

uncommon anomaly in the specie. A left lateral thoracotomy approach

was performed. The use of a vascular titanium clip is a technique that

requires little dissection during the surgery, reducing complication risks

in the postoperative. The procedure was successfully performed without

complications and minimal bleeding.

Key-words: congenital heart disease, shunt, surgery, feline, thorax.

Submitted in June 2016.

Accepted in October 2016.

Oliveira A. L. A.

PhD in Surgery - Universidade

Federal do Rio de Janeiro (UFRJ).

Associated professor / Universidade

Estadual do Norte Fluminense

(UENF), Campos dos Goytacazes,

Brazil. Laboratory of Animal Clinic

and Surgery (LCCA). E-mail:

[email protected]

Da Silva T. O. B.

Master science student at UENF,

Campos dos Goytacazes, Brazil.

Atallah F. A.

PhD in animal science, UENF,


Cadena S. M. R.

Master science student at UENF,


Antunes F.

PhD in Farmacology (UFRJ).

Associated professor / UENF,


Scheffer J. P.

Doctor science student at UENF,


Cabral M.

Autonomous veterinary, Rio de

Janeiro, Brazil.

Souza H. J. M.

PhD. Associated professor of Clinic

and Surgical Pathology at UFRJ,

Rio de Janeiro, Brazil.

mailto:[email protected]


639

Introduction

The incidence of congenital heart disease in cats

seen in clinical practice is one case per 1,000 patients (1).

Anomalies of the endocardial cushion defects are

considered the most prevalent in cats, such as ventricular

septal defect, partial or complete atrioventricular septal

defect, atrioventricular valve dysplasia (2) where the left

atrioventricular valve is more affected than the right.

Aortic stenosis and pulmonary stenosis are relatively rare,

and the persistent ductus arteriosus (PDA) (3).

In cats, the PDA may occur alone or coexist with

other malformations, especially with ventricular septal

defect (4) (5). The ductus arteriosus is a variable channel

length and diameter similar to the descending aorta and is

a structure present in mammalian fetuses. Although the

thickness of its wall is similar to the wall thickness of the

aorta and pulmonary artery, its middle layer is basically

composed of smooth muscle, different from the layer of

elastic fibers found in aorta and pulmonary arteries (6).

During embryogenesis, the ductus arteriosus originates

from the sixth left aortic arch, acting as a vascular

connection between the pulmonary artery and the

descending aorta. This connection allows the flow of

blood from the nonfunctional fetal lungs to the aorta,

allowing fetal perfusion (7). After birth, onset of

respiration and increased blood oxygen tension contribute

to the closing of the duct, separating the systemic

circulation of the pulmonary circulation (8).

The blood flow deviation through the shunt in the

left-right direction results in increased pulmonary

circulation, compromising its complacency and

generating extender work of breathing. As a result, an

overloaded volume is observed in the left atrium and

ventricle and pulmonary edema may occur (6).

In 2001, Buchanan (9) reported that this

overloaded volume in the left atrium and ventricle

generates an eccentric hypertrophy, leading to cardiac

remodeling and predisposing patients to develop left heart

failure. Over time, the chronic increased volume in the

pulmonary circulation leads to a series of morphological

and vasculature pulmonary changes, such as arteriolar

hypertrophy, occlusion of arterioles and lung capillaries,

leading to increased vascular resistance and pulmonary

blood pressure (6). In cats, the literature on pulmonary

arterial hypertension secondary to the presence of PDA is

scarce (10). When the pulmonary vascular resistance


640

exceeds systemic vascular resistance, the shunt becomes

reverse and the dynamics of the blood flow changes to

right-left (6). It is generally observed early reversal of the

shunt in patients with a high diameter of the duct (11)

(10). Echocardiography is the most appropriate test to

confirm the diagnosis of PDA, evaluate the impact caused

by the shunt and possible associated lesions (6).

Definitive treatment of PDA is based on surgical

correction, the account of the first successful surgery of

this anomaly in feline dates from 1975 (12). The surgery

consists in closing the duct using ligation with suture or

via a vascular clip. It is further described intravascular

catheterization technique occlusion (13). The closing of

duct through ligation with suture leads to some risks that

could compromise the procedure. The tissue around the

duct is thin and friable, and should be carefully dissected

along with the location and removal of the vagus nerve

and the recurrent laryngeal nerve. The passage of the

suture and the subsequent ligation of the voltage can

damage and tear the duct, leading to bleeding and may

compromise the patient's life.

The use of titanium vascular clip technique

requires little dissection greatly reducing complications

Figure 1 Endoclip with

Vascular Clip.

and risks during the procedure and the postoperative (14).

The technic is developed by thoracoscopy, a less invasive

method with reduced surgical trauma and postoperative

pain and a shorter surgical recovery by the animal, when

compared to traditional technique by thoracotomy.

One factor that may prevent the use of vascular

clip is the diameter of the duct, which cannot exceed 12

mm in diameter, as this is the largest vascular clip size

found. Other problems related to use of the clip include

risk of shunt and recanalization interference clip with

imaging tests such as CT scans, X-rays and magnetic

resonance imaging (15).

The prognosis for feline PDA carrier untreated is

unfavorable, and 50% or more of patients die after


641

diagnosis. Cats with chronic PDA are likely to develop

left congestive heart failure and pulmonary edema.

Patients underwent surgical treatment have an excellent

prognosis (1).

In the present work was carried out occlusion of

PDA in a feline, with the use of vascular titanium clip

(SLS-clip®, Vitalitec) through thoracotomy, aiming more

security and reduced risk of trans-operative complications

compared with ligation technique with suture.

Figure 2 Vascular SLS-clip® Clip.

Anamnesis

A 12-months-old female, mongrel feline, with

diagnosis of PDA and left-right deviation was referred

to the surgery sector of the Animal Experimentation

Unit. The complete blood count and biochemical test

Figure 3 Feline taken to the operating sector for PDA correction.

were within normal limits, and the Doppler

echocardiographic examination revealed a left

ventricle dilatation, thickening of pulmonary valve

leaflets and presence of turbulent flow coming from

the right ventricular outflow tract with continuous and

turbulent flow in pulmonary artery due the presence of

left to right 0,42 cm diameter shunt. Also, the

evaluation revealed a 14,1 mmhg pulmonary pressure


642

gradient with 187,7 cm/s speeding, suggesting

pulmonary arterial overload. The left ventricular

systolic function remained normal.

During preoperative physical examination by the

surgical team were found normal colored mucosa

membranes, heart rate normal value, but with the presence

of systolic murmur III / VI, more audible in the left

hemithorax region. As there was the presence of cardiac

murmur, which was audible in the left hemithorax ruled

out the possibility of shunt reversal. Auscultation of lung

fields was normal, not observable increase in respiratory

effort was observed.

Patient preparation for surgery was performed by

venipuncture and fluid to Ringer's lactate based, followed

by the pre-anesthetic medication administration

associating acepromazine (0.1 mg / kg, IM) and

midazolam (0.2 mg / kg , IM). After conducting extensive

trichotomy of the left hemithorax, the patient was induced

with propofol (4 mg / kg, IV) and the Anesthesia was

maintained with isoflurane (1.5 to 2.0 V%).

For analgesia fentanyl infusion was administered

(0.8 mg / kg / minute) and antisepsis of the surgical region

was performed with povidone iodine.

Figure 4 Persistent ductus arteriosus (PDA). AAo: Artery Aorta. AP: Pulmonary Artery.

Figure 5 PDA occlusion with Bakey tweezers. AP: Pulmonary Artery.


643

The surgical approach was performed through a

thoracotomy in the fourth intercostal space, followed by

separation of the lung lobes with the aid of sterile gauze

moistened with saline. The vagus nerve and the recurrent

laryngeal nerve were identified and kept away from the

surgical field, delicately, then the PDA was identified

visually and with digital touch that provided perception of

blood flow through the aorta to the pulmonary artery this

technique orders the minimum dissection reducing the risk

of rupture of the duct.

A Bakey clamp was placed to occlude the duct,

the occlusion was maintained for 5 minutes to assess the

possible right pulmonary artery accidental occlusion that

represents hemodynamic changes, which would be

indicated in the parameters of capnography , oximetry,

ECG, heart rate and blood pressure observed in the

multiparameter monitor.

There was an artery engorgement descending

aorta due to shunt closure, bypassing the volume and

thereby increasing the blood flow to the aorta. After

removal of the Bakey clamp was positioned and fixed the

endoclip 2 titanium vascular clips (SLS-clip®, Vitalitec)

for permanent occlusion of the duct.

Figure 7 Positioning the Vascular SLS-clip® Clip.

Figure 6 Fixing Vascular SLS-clip® Clip permanently occluding the PDA.


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In sequence was carried out to thoracotomy with

interrupted sutures of the ribs using polyglycolic acid 0

(Ethicon, Dexon), positioning them immediately cranial

and caudal. Finally, there was thoracentesis restoring

negative intrathoracic pressure. The animal returned from

anesthesia and was taken to hospital where he remained

for a period of 24 h without complications. During the

postoperative Doppler echocardiography was observed an

effective ductal occlusion and the pulmonary gradient

pressure reduced to 1,82 mmhg.

Discussion

We opted for the realization of left thoracotomy,

instead of thoracoscopy or catheterization technique for

this surgical procedure, due to the deep knowledge of the

surgical technique. The choice of using the vascular

titanium clip was based on the report of Mandhan et al

(14) that compared the complications caused by the use of

ligation with suture and occlusion with the titanium clip,

which observed that in the first case there is an increased

risk of duct injury, leading to rupture and hemorrhage,

during dissection and resection of the duct during surgery.

In addition Panagopoulos et al (16) indicate a rate of 3 -

5% of the duct recanalization after ligation with suture.

The use of titanium vascular clip requires

minimal dissection of the duct giving greater simplicity

and rapidity to the procedure, however acquiring non-

absorbable and monofilament sutures is less expensive

when compared to endoclip and titanium vascular clip. In

situations where the diameter of the duct is greater than 12

mm, the surgical procedure for the PDA correction of

reference is through ligature, suture or with use of a duct

occlusion device for catheterization, due to the biggest

clip occlusion device has a 12 mm diameter.

Figure 8 Duct occluded with

titanium endoclip.


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Despite being provided complications PDA

surgery in dogs as: hemorrhage, pulmonary trauma, heart

failure, arrhythmias (17) (18) with a mortality rate ranging

from 1.6 - 11% (19), during the current study were not

observed changes that would compromise the procedure.

Conclusion

It is concluded that the use of the vascular

occlusion clip PDA was an effective technique, since at

the examination of postsurgical Doppler ecocardiography

there was no remaining flux, also being a safe procedure,

since the risk of complications during surgery were

minimal.

Funding

The authors received no specific grant from any funding

agency in the public, commercial or not-for-profit sectors

for the preparation of this case report.

Conflicts of interest

The authors do not have any potential conflicts of interest

to declare.

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first case report of patent ductus arteriosus occlusion with titanium endoclip … · 2018. 1....

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