Is lacerating the pulmonary vein and aorta (Atrial Septal Defect) a risk of ASD (Atrial Septal Defect) procedure?

Risks of Pulmonary Vein and Aortic Laceration During ASD Closure Procedures

Vascular injury including pulmonary vein avulsion and aortic laceration is a rare but serious potential complication of atrial septal defect (ASD) closure procedures, particularly during surgical repair or catheter-based interventions. 1

Vascular Injury Risks in ASD Procedures

Catheterization-Related Risks

• Pulmonary vein injury: Specifically mentioned in guidelines as a rare but documented complication during balloon atrial septostomy procedures 1
• Inferior vena cava tears: Can occur during catheter manipulation 1
• Cardiac erosion: One of the most severe late complications of device closure that can potentially involve the aorta or other adjacent structures 2

Surgical Repair Risks

• Vascular injury: Though rare with modern surgical techniques, the anatomical proximity of pulmonary veins and aorta to the atrial septum creates inherent risk
• Major complications rate: In elderly patients (>60 years), surgical ASD closure has shown a 23% major complication rate, higher than reported in younger populations 1

Risk Factors for Vascular Complications

Anatomical Considerations

• Sinus venosus defects: These have higher risk due to their location near the superior vena cava and right pulmonary veins 1, 3
• Deficient rims: ASDs with inadequate tissue margins for device anchoring increase risk of erosion into adjacent structures 3
• Large defects: Defects >38mm requiring surgical closure may have more complex anatomy 3

Patient-Related Factors

• Pulmonary hypertension: Patients with elevated pulmonary pressures have increased surgical risk 1
• Advanced age: Elderly patients have higher complication rates with both surgical and device closure 1

Prevention Strategies

Imaging Guidance

• Biplane fluoroscopy: Essential during septostomy to confirm position before manipulation 1
• Echocardiography: Either transesophageal (TEE) or intracardiac (ICE) provides critical real-time guidance 4
• Proper device sizing: Critical for preventing erosion into adjacent structures 3

Procedural Considerations

• Center experience: All CHD interventions should be performed in centers with experience, ideally with multiple operators 1
• Case discussion: Multidisciplinary conference to weigh pros and cons of medical, interventional, and surgical approaches 1
• Operator expertise: Interventionalists trained in pediatric cardiology or adult congenital intervention likely have more experience with ASD closure 1

Procedure Selection to Minimize Risk

• Percutaneous closure: Preferred for secundum ASDs with suitable anatomy and adequate rims for device anchoring 3
• Surgical repair: Required for sinus venosus defects (higher risk for pulmonary vein involvement), coronary sinus defects, primum ASDs, or large secundum ASDs with deficient rims 3
• Minimally invasive approaches: For secundum ASDs too large for device closure, ministernotomy and thoracoscopic approaches may reduce risk 1

Post-Procedure Monitoring

• Device complications: Evaluation recommended at 3 months to 1 year after closure and periodically thereafter 3
• Echocardiography: To assess for any evidence of vascular compromise or erosion 3
• Clinical follow-up: Annual follow-up recommended for patients with persistent/residual pulmonary arterial hypertension or other complications 3

While vascular injuries during ASD procedures are rare, they represent serious potential complications that require proper prevention strategies, experienced operators, and appropriate procedure selection based on defect anatomy and patient characteristics.