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Tough Calls: Case 10

ASD with azygous continuation of interrupted IVC

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 


52 year old female, previously diagnosed in China with secundum ASD and RV enlargement. Had a transfemoral attempt to close the ASD but they were unable to reach the right atrium. A MRI confirmed the suspected diagnosis: azygous continuation of the interrupted IVC with a 1.3 x 1.5 cm ASD.

How would you proceed? 

Expert Approaches

Hover over an experts image to view their approach.

  • Check liver status

  • RIJ access and place catheter in lateral/anterior hepatic vein 

  • Transhepatic access; insert 8fr sheath for balloon sizing

  • Plan to use Amplatzer device to minimize sheath size

  • Close hepatic tract with coil on way out

Dr. Ryan Callahan

Boston Children's Hospital

Division of Invasive Cardiology

Assistant Professor of Pediatrics, Harvard Medical School 

  • Two options: Steerable sheath such as theAgilissheath from the RIJVand across the ASD to deploy either a Gore Septal Occluder orAmplatzer Septal Occluder. Alternatively, access can be obtainedtranshepaticinto a hepatic vein tosuprahepaticIVC which will directeasily across the ASD for delivery ofa device

Dr. Matt Crystal

New York-Presbyterian & Morgan Stanley Children's Hospital

Assistant Professor of Pediatrics, Columbia University Medical Centre
Associate Director, Pediatric Cardiac Catheterization Cardiology

  • Transhepatic access using Chiba needle – with dye, microwire, and ultrasound (and collaboration with Pediatric or IR colleagues with most experience)

  • Close ASD per usual

  • Small vascular plug while removing sheath from distal vein.

Dr. Harsimran SIngh

Director, Adult Congenital Heart Disease,

Director, Cardiovascular Disease Fellowship, Weill Cornell Medicine

  • FIRST THINGS FIRST! Where is the ASD? What are the rims? Do youn eed balloon sizing? If suitable-You will need TEE guidance...

  • Consider hepatic access: Local anesthesia, small needle access with injection of contrast to confirm hepatic vein (contrast goes to RA not into liver)-pass wire, serial dilation to accommodate long sheath over wire into LA. If anatomy is as stated either place 30 mm GSO device or16-17 mm ASO. Close tract on way out with AVPII

  • SVC access: Use steerable sheath to secure wire into LA, placement of long sheath. Consider using appropriate size ASO device based on confirmatory TEE imaging

Dr. Allison Calbalka

Professor of Pediatrics, Mayo Clinic College of Medicine

Consultant, Pediatric Cardiology 

Director, Congenital Cardiac Laboratory

Mayo Clinic, Rochester, Minnesota

  • RIJ  Approach with steerable sheath or transhepatic approach

Dr. Zahid Amin

William B. Strong Chair and Professor and Section Chief

Division of Pediatric Cardiology 
Congenital and Structural Heart Disease
Children’s Hospital of Georgia, Augusta University

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