Transjugular Closure of Atrial Septal Defects in Children using the Occlutech Steerable Sheath

Background
Transcatheter secundum atrial septal defect (ASD) closure in children with interrupted inferior vena cava (I-IVC) requires modification of the standard technique. Transjugular (TJ), transfemoral (TF) and transhepatic (TH) approaches have been reported, though TH access carries a higher risk of serious bleeding complications. TJ is therefore the preferred approach, however maintaining stable position during device deployment can be challenging. A 180°curve delivery sheath may assist for smaller defects, though is not available to accommodate larger ASD devices. We report a novel TJ approach in 2 children with I-IVC and large ASDs using the Occlutech Steerable Sheath.

Methods
The Occlutech Steerable Sheath is designed for improved access to the left atrium from TF approach. The sheath is braided with a soft tip which can flex 180°in a small 39 mm curve which is maintained during device delivery. It is manufactured in two diameters (12 Fr/15.9 Fr and 14 Fr/16.8 Fr; inner/outer) with length of 86cm. Access was obtained in the right internal jugular vein with an Amplatzer Extra Stiff wire advanced to the left lower pulmonary vein. The defects were balloon sized in standard fashion using TEE guidance. A 12 Fr Occlutech sheath was advanced and flexed to the left atrium. Maintaining flexion, the devices were deployed with sheath retracted in usual fashion. Children with I-IVC who were referred for transcatheter ASD closure at 2 centers were considered for closure via this technique.

Results
Two children underwent cardiac catheterization: 6 years 21 kg – previously failed attempt using 12 Fr Amplatzer 45°sheath; and 14 years 71 kg. Baseline hemodynamics were normal with large left to right shunt (Qp:Qs 1.9-2.1:1). ASD dimensions at rest and with balloon sizing were 26/31 mm and 16/24 mm. The defects were closed with Occlutech 33 mm and 27 mm ASD Occluders respectively. There were no procedural compilations and no residual leak 10-18 months post occlusion.

Conclusions
This is the first report of TJ ASD closure using the Occlutech Steerable Sheath, demonstrating safety and feasibility in children with large secundum ASDs and I-IVC. Improved sheath stability during deployment of larger devices should increase the probability of successful closure.