Bilateral Transbrachial Intracardiac Echocardiography-Guided Patent Foramen Ovale Closure in Patient With Bilateral Deep Vein Thrombosis

J INVASIVE CARDIOL 2022;34(8):E643-E644.

Key words: cryptogenic stroke, ICE, stroke, PFO, PFO closure

A 56-year-old male presented with a past medical history remarkable for recurrent deep vein thrombosis (DVT) on anticoagulation and cryptogenic stroke. Transesophageal echocardiography with a positive bubble study revealed that he had a large patent foramen ovale (PFO). The patient has a calculated risk of paradoxical embolism (RoPE) score of 7.

Bilateral femoral venogram was performed, confirming persistent chronic bilateral DVT (Figures 1A and 1B). Therefore, a transbrachial venous access approach was utilized. A right (12-Fr) and left (10-Fr) brachial vein access was obtained under ultrasound guidance. A 10-Fr intracardiac echocardiography (ICE) catheter (St Jude Medical) was inserted through the left brachial vein. The defect then crossed via the right brachial vein with an 8.5-Fr Agilis catheter (Abbott Cardiovascular) and exchanged for a 9-Fr 180 degree Amplatzer TorqVue sheath (St Jude Medical). However, the TorqVue sheath position was unstable in the left atrium with an unfavorable deployment angle. The intended 35-mm PFO device could fit into the Agilis sheath. Thus, a 12-Fr Oscor sheath (Oscor, Inc) was placed across the PFO (Figure 1C) under ICE guidance (Figure 1E). The Oscor sheath was then deflected upward for better alignment for PFO closure (Figure 1D). A 35-mm Amplatzer PFO occluder device (Abbott Cardiovascular) was deployed across the defect under ICE guidance (Figure 1F). Left brachial access (10 Fr) was closed with a pressure dressing, while right brachial access (12 Fr) was closed with a single Perclose device (Abbott Cardiovascular) and a pressure dressing. Postoperative transthoracic echocardiography showed stable device with no pericardial effusion.

At 1-month follow-up, the patient had perfectly healed brachial wounds (Figures 1G and 1H). To our knowledge, this is the first report on ICE-guided PFO closure via a bilateral transbrachial approach.

Affiliations and Disclosures

From the Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Villablanca is a consultant for Edwards Lifesciences and Teleflex. Dr O'Neill has served as a consultant for Abiomed, Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St Jude Medical; and serves on the Board of Directors of Neovasc, Inc. Dr Wang is a consultant to Edwards Lifesciences, Abbott, Neochord, Boston Scientific; reports research grant support from Boston Scientific to employer (Henry Ford Health System). Dr Chiang reports no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 17, 2022.

Address for correspondence: Michael Chiang, MD, Henry Ford Hospital, Center for Structural Heart Disease, CFP 4th floor, 2799 W Grand Blvd, Detroit, MI 48202. Email: michaelcschiang@gmail.com