Delayed surgical management of an Amplatzer device migration into the aortoiliac bifurcation

Endovascular procedures are nowadays largely performed for the treatment of congenital heart diseases.There are specific risks associated with these minimal invasive procedures. 1 We present the case of a 23-year-old woman who presented with lower limb claudication after migration of a septal occluder into her aortic bifurcation (Amplatzer, AGA Medical, Golden Valley, MN) (A/Cover).The patient provided written consent for the publication, including the use of images. CASEA 23-year-old female patient was diagnosed with atrial septal defect after detection of a heart murmur diagnosis during a routine examination.The initial evaluation revealed two atrial septal defects measuring 10 and 11 mm, with no impact on cardiac function or functional symptoms.She subsequently underwent placement of two 10-mm septal occluders (Amplatzer) in another hospital.Six months after the procedure, she presented with claudication symptoms.A transesophageal echocardiography was performed and visualized only a single septal occluder.A computed tomography scan was then performed and revealed that the second device had migrated into the aortoiliac bifurcation (B).We believe that the most likely cause of migration was undersizing of the septal occluder.An initial attempt to remove the device using a percutaneous approach with a snare was unsuccessful.She was then referred to our institution with severe claudication.Femoral and distal pulses were palpable but diminished.Doppler ultrasound examination measured the peak systolic velocities at 260 cm/s and 280 cm/s at the origin of the left and right common iliac arteries, respectively.After a multidisciplinary discussion, we opted for an open surgical retrieval associated with the implantation of another septal occluder during the same procedure under general anesthesia.Because the symptoms began 6 months prior, we hypothesized that the device would likely be endothelialized and tightly attached to the aorta, which explains the failed endovascular retrieval attempt.Under general anesthesia, through a mini laparotomy, the aorta was dissected through a transperitoneal approach.The aorta below the inferior mesenteric artery and the origin of both common iliac arteries were controlled.There was a significant inflammatory process surrounding the aorta.After injection of 50 IU/kg of intravenous heparin, the aorta was clamped below the inferior mesenteric artery, and both common iliac arteries 20 mm after their origin.A longitudinal aortotomy was performed.