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Transjugular closure of a large patent ductus arteriosus in a 1100-g infant

Published online by Cambridge University Press:  11 May 2026

Majed Kanaan Open the ORCID record for Majed Kanaan [Opens in a new window] ,
Stefan Ostermayer ,
Blaz Kosmac ,
Wolfgang Lawrenz  and
Ulrike Herberg
Majed Kanaan*
Affiliation:
Pediatric cardiology, Uniklinik RWTH Aachen, Germany
Stefan Ostermayer
Affiliation:
Pediatric cardiology, Uniklinik RWTH Aachen, Germany
Blaz Kosmac
Affiliation:
Pediatric cardiology, Uniklinik RWTH Aachen, Germany
Wolfgang Lawrenz
Affiliation:
Pediatric cardiology, Uniklinik RWTH Aachen, Germany
Ulrike Herberg
Affiliation:
Pediatric cardiology, Uniklinik RWTH Aachen, Germany
*
Corresponding author: Majed Kanaan; Email: majk10@hotmail.com
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Abstract

The patent ductus arteriosus is the most common cardiac anomaly in neonates. Haemodynamically significant patent ductus arteriosus is associated with increased morbidity and mortality in preterm babies. Transfemoral venous access is the standard route for patent ductus arteriosus device closure, even in very low birth weight infants. The transjugular approach is also an alternative, but it is more challenging, especially in preterm infants. We report a successful transjugular closure of a patent ductus arteriosus in a 1100‑g infant (the smallest worldwide), where transfemoral access was not possible due to bilateral iliofemoral venous thrombosis.

Keywords

Patent ductus arteriosus closurepreterm infantsPiccolo

Information

Type
Case Report
Information
Cardiology in the Young , Volume 36 , Issue 4 , April 2026 , pp. 854 - 856
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Copyright
© The Author(s), 2026. Published by Cambridge University Press

Introduction

The patent ductus arteriosus is the most common cardiac anomaly in neonates. Reference Mitchell, Korones and Berendes1 In premature babies, incidence varies between 20 and 60% (depending on population and diagnostic criteria). Reference Hajjar, Vaksmann and Rakza2 Haemodynamically significant patent ductus arteriosus increases morbidity and mortality in these vulnerable patients. Reference Baruteau, Fraisse, Butera and Bautista-Rodriguez3 The transfemoral venous approach is the standard route for closure of patent ductus arteriosus; however, experience with the transjugular approach is very limited. Reference Herron, Forbes and Kobayashi4

Case report

A 7-week-old premature female with a weight of 1100 g was admitted to our department for transcatheter closure of a patent ductus arteriosus (Figure 1). The patient was multimorbid and ventilated since birth. The right femoral vein was found to be occluded on sonography. After puncture of the left femoral vein under sonographic guidance, occlusion of the left iliac vein was diagnosed by angiography. The venous blood of the lower extremities drained via the paravertebral plexus. Because of the venous occlusion of the lower extremities, we decided to use the transjugular access. After puncture of the right internal jugular vein, a 4 French sheath (Terumo Europe N.V. Leuven, Belgium) was placed. A 4 Fr Judkins right catheter (JR4 2.5; Cordis corp., Florida, USA) was introduced into the right atrium. With the catheter in situ, a 0.014-inch Balance Middleweight guidewire was advanced sequentially across the tricuspid valve, the pulmonary valve, and the patent ductus arteriosus. Subsequently, the JR catheter was advanced over the wire and placed in the descending aorta. An angiogram was performed and showed a large patent ductus arteriosus which measured 3 × 11 mm (Figure 2). The Judkins right catheter was removed after placing a second BMW wire in the descending aorta via the JR catheter. The Piccolo implantation catheter (AmplatzerTM TorqueVueTM LP, Abbott Medical, MN, USA) was introduced in the jugular vein over the two BMW wires. However, the TorqueVue LP catheter was too stiff to be advanced into the pulmonary artery due to insufficient support from the wires. The TorqueVue LP catheter pushed the wires into the inferior vena cava. The TorqueVue LP catheter was removed, and the jugular sheath was replaced by a long 4-F introducer sheath (Terumo, 45cm Terumo Europe N.V. Leuven, Belgium) over which the JR catheter was advanced into the ductus arteriosus. The 45cm Terumo introducer sheath was advanced over the JR catheter into the ductus arteriosus. Subsequently, the JR catheter was replaced by the TorqueVue LP catheter that was advanced through the long supporting Terumo sheath into the ductus arteriosus. A 4 × 2 mm Amplatzer Piccolo Occluder (Abbott Medical, MN, USA) was advanced and positioned inside the duct via the TorqueVue catheter. Total procedure time was 72 minutes, with a fluoroscopy time of 7.9 minutes and a total radiation dose of 12 cGy·cm2. Post-closure echocardiogram demonstrated successful closure without any obstruction of the left pulmonary artery or descending aorta after device release.

Figure 1.

Baseline transthoracic echocardiography shows the presence of large patent ductus arteriosus (PDA) with a left-to-right shunt.

A cross-sectional echocardiogram image showing a large patent ductus arteriosus (PDA) with a left-to-right shunt.
Figure 1 Long description

The image consists of two panels. The left panel shows a grayscale echocardiogram image with a labeled arrow pointing to the patent ductus arteriosus (PDA). The right panel displays a color Doppler echocardiogram image highlighting the PDA with a left-to-right shunt, indicated by the flow of blood in blue and red colors. The PDA is a persistent opening between the aorta and the pulmonary artery that normally closes shortly after birth. The color Doppler imaging helps visualize the direction and velocity of blood flow through the PDA, showing the left-to-right shunt where oxygenated blood from the aorta flows back into the pulmonary artery.

Figure 2.

Patent ductus arteriosus angiogram (A, frontal projection; B, lateral projection). Saved fluoroscopy showing the Piccolo device position (C, lateral projection; D, frontal projection). PDA, patent ductus arteriosus. JR, Judkin right catheter.

Angiogram images showing patent ductus arteriosus and Piccolo device position.
Figure 2 Long description

The image consists of four angiogram projections. The first two images (A and B) display the patent ductus arteriosus (PDA) in frontal and lateral views, respectively. The labels indicate the PDA, aorta, and Judkin right catheter. The next two images (C and D) show the position of the Piccolo device in lateral and frontal projections. The labels highlight the Piccolo device and the torque view in the lateral projection.

Post-procedure echocardiogram (Figure 3) showed no residual shunt across the duct. The patient was extubated 2 days after closure of the patent ductus arteriosus and discharged after 2 weeks. The right internal jugular vein was sonographically patent post-intervention. At 3 months’ follow-up, the patient was well and the echocardiogram revealed no residual shunt and no obstruction of the left pulmonary artery or the aortic arch.

Figure 3.

Post-closure transthoracic echocardiography coloured image shows the Piccolo device without a residual shunt or LPA stenosis. LPA, left pulmonary artery.

A transthoracic echocardiography image showing the Piccolo device in the heart without a residual shunt or left pulmonary artery stenosis.
Figure 3 Long description

The transthoracic echocardiography image displays the Piccolo device positioned within the heart. The image highlights the absence of a residual shunt and no stenosis in the left pulmonary artery. The Piccolo device is clearly visible, indicating successful placement. The left pulmonary artery is labeled as LPA, and an arrow points to the Piccolo device. The image uses color Doppler to show blood flow, with blue and red indicating different directions of flow. The overall structure of the heart is visible in the background, providing context for the device's location.

Discussion

Transcatheter closure of patent ductus arteriosus in infants is a safe and effective method. Reference Wang, Wu and Hwang5,Reference Baruteau, Hascoët and Baruteau6 Transfemoral venous access remains the standard approach for device closure of patent ductus arteriosus. Very low birth weight infants are prone to develop iliofemoral venous thrombosis due to central venous catheters. Reference Nowak-Gottl, von Kries and Gobel7 Thus, a transfemoral approach may be precluded by thrombosis of the femoral, iliac, or inferior caval vein. In this case, transjugular access may be used as an alternative. Reference Herron, Forbes and Kobayashi4,Reference Fernandes, Assaidi, Baruteau and Fraisse8

The transjugular route for device closure of patent ductus arteriosus is more challenging and can lead to haemodynamic instability due to significant tricuspid valve regurgitation caused by the angulation of the delivery catheter. Furthermore, the risk of mechanical ventricular arrhythmia is not negligible. In the present case, a long 4 Fr sheath was advanced over a 0.014-inch guidewire to facilitate the placement of the TorqVue LP delivery catheter. As an alternative to this approach, the JR catheter could be exchanged over a 0.035-inch guidewire for the TorqVue LP catheter. The patient tolerated the procedure (except for a temporary haemodynamic deterioration during the passage of the tricuspid valve with the implantation catheter) without major complications. Transjugular closure of patent ductus arteriosus was feasible in the described case; however, further experience is needed to confirm the feasibility and safety of this approach in preterm.

References

Mitchell, SC, Korones, SB, Berendes, HW. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 1971; 43: 323–332. DOI: 10.1161/01.CIR.43.3.323.CrossRefGoogle Scholar
Hajjar, ME, Vaksmann, G, Rakza, T. Severity of the ductal shunt: a comparison of different markers. Arch Dis Child Fetal Neonatal Ed 2005; 90: F419–F422. DOI: 10.1136/adc.2003.027698.CrossRefGoogle ScholarPubMed
Baruteau, A-E, Fraisse, A, Butera, G, Bautista-Rodriguez, C. The transcatheter closure of patent ductus arteriosus in extremely low-birth-weight infants: technique and results. J Cardiovasc Dev Dis 2023; 10(12): 476. DOI: 10.3390/jcdd10120476.Google Scholar
Herron, C, Forbes, TJ, Kobayashi, D. Transjugular venous approach for Piccolo patent ductus arteriosus closure in a 1.4 kg infant. Cardiol Young 2022; 32(1): 111–112. DOI: 10.1017/S1047951121004601. Epub 2021 Dec 6.CrossRefGoogle Scholar
Wang, JK, Wu, MH, Hwang, JJ, et al. Transcatheter closure of moderate to large patent ductus arteriosus with the Amplatzer duct occluder. Catheter Cardiovasc Interv 2007; 69: 572–578.Google ScholarPubMed
Baruteau, AE, Hascoët, S, Baruteau, J, et al. Transcatheter closure of patent ductus arteriosus: past, present and future. Arch Cardiovasc Dis 2014; 107: 122–132.CrossRefGoogle ScholarPubMed
Nowak-Gottl, U, von Kries, R, Gobel, U. Neonatal symptomatic thromboembolism in Germany: two year survey. Arch Dis Child 1997; 76: F163–F167.CrossRefGoogle ScholarPubMed
Fernandes, P, Assaidi, A, Baruteau, A-E, Fraisse, A. Transcatheter closure of a large patent ductus arteriosus using jugular access in an infant. J Thorac Dis 2018; 10(3): E207–E209. DOI: 10.21037/jtd.2018.02.54.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1. Figure 1 long description.Baseline transthoracic echocardiography shows the presence of large patent ductus arteriosus (PDA) with a left-to-right shunt.

Figure 1

Figure 2. Figure 2 long description.Patent ductus arteriosus angiogram (A, frontal projection; B, lateral projection). Saved fluoroscopy showing the Piccolo device position (C, lateral projection; D, frontal projection). PDA, patent ductus arteriosus. JR, Judkin right catheter.

Figure 2

Figure 3. Figure 3 long description.Post-closure transthoracic echocardiography coloured image shows the Piccolo device without a residual shunt or LPA stenosis. LPA, left pulmonary artery.