Technical Innovation
Embolization of the Patent Ductus Venosus in
an Adult Patient
Takuji Araki 1, Toshiyuki Konishi 2, Shinichiro Yasuda 2, Takanori Osada 2, Tsutomu Araki 1
American Journal of Roentgenology 2003.180:716-718.
I n fetal circulation the ductus veno-
sus is a connection between the left
portal vein and the inferior vena
cava that closes immediately after birth. Re-
ports of patent ductus venosus in children are
rare [1–4], and in adults, even rarer [5, 6]. Al-
though a patent ductus venosus may be thought
of as a kind of portosystemic shunt, most intra-
hepatic portosystemic venous shunts, which of-
ten result in portosystemic encephalopathy, are
congenital shunts between the intrahepatic por-
tal vein and the peripheral hepatic vein [7, 8]. A
patent ductus venosus may be treated by con-
servative therapy or by surgical banding [9]. To
our knowledge, only three reports about the
transcatheter treatment of patients with this dis-
ease have been published [3, 4, 6].
We present a case of a 45-year-old woman
with direct communication between the left
portal vein and the inferior vena cava that was a
patent ductus venosus. An arterial portogram
revealed a markedly dilated left portal vein and
a narrowed right portal vein. While the shunt
was temporarily occluded by an inflated bal-
loon, the shunt was successfully treated by em-
bolization with the use of detachable coils via a
retrograde transcaval route.
Case Report
In August 1997, a 45-year-old woman with
a 2-year history of disturbance of conscious-
Received February 11, 2002; accepted after revision August 27, 2002.
1
Department of Radiology, Yamanashi Medical University, 1110 Shimokato, Tamaho, Nakakoma-gun, Yamanashi, 4093898, Japan. Address correspondence to Tsutomu Araki.
2
Department of Internal Medicine, Kofu Kyoritsu Hospital, 1-9-1 Takara, Kofu-city, Yamanashi, 400-0034, Japan.
AJR 2003;180:716–718 0361–803X/03/1803–716 © American Roentgen Ray Society
716
ness and headache presented to our hospital.
She had been diagnosed at another hospital as
having hepatic encephalopathy due to hyper-
ammonemia of unknown origin and was con-
servatively treated with no improvement in
her condition. The results of routine labora-
tory tests were as follows: serum albumin, 3.0 g/
dL (normal, 3.4–4.9 g/dL); and total bilirubin,
1.7 mg/dL (0.2–1.1 mg/dL). Blood ammonia
was elevated at 193 µg/dL (12–66 µg/dL).
Laboratory results indicated that hepatitis C
virus antibody and hepatitis B surface antigen
were not present. There was no clinical evi-
dence of liver cirrhosis.
Contrast-enhanced abdominal CT re-
vealed an abnormal vein between the left
portal branch and the inferior vena cava
passing through the fissure for the ligamen-
tum venosum (Figs. 1A and 1B). An arterial
portogram revealed the abnormal vein con-
necting the umbilical portion of the portal
vein directly to the inferior vena cava. Al-
though the main portal trunk and its left
branch were dilated, the right branch was
narrowed (Fig. 1C). A celiac arteriogram re-
vealed compensatory dilatation of the he-
patic artery. There was no communication
between the abnormal vein and any hepatic
veins, and the diagnosis was a patent ductus
venosus. The patient opted for a transcatheter
procedure, not surgery, for treatment of the
patent ductus venosus.
From the right internal jugular vein, a 6-
French catheter with a 20-mm-diameter latex
balloon was inserted into the abnormal vein.
When the abnormal shunt was temporarily oc-
cluded by the inflated balloon, the patient’s portal
venous pressure increased from 18 to 20 mm Hg.
An arterial portogram obtained during temporary
balloon occlusion showed good portal venous
flow and right portal branches that were slightly
wider than those without balloon occlusion.
Therefore, we assumed that occlusion of the ab-
normal vein did not affect the portal venous cir-
culation. The diameter of the abnormal vein was
10 mm, and the aneurysmal dilatation was 16
mm near the umbilical portion of portal vein.
A microcatheter (Renegade; Boston Scien-
tific, Natick, MA) was introduced through a
balloon catheter into the aneurysmal portion of
the abnormal vein. A temporary occlusion bal-
loon was inflated in the 10-mm-diameter shunt.
We prepared snares and cardiac muscle biopsy
forceps to treat migration of coils should that
become necessary. Embolization was per-
formed with detachable coils (IDC [interlock-
ing detachable coil]; Target, Fremont, CA) and
microcoils (Tornado; Cook, Bloomington, IN)
under temporary balloon occlusion of the shunt
to control the blood flow (Fig. 1D). We placed
nine interlocking detachable coils, ranging in
diameter from 8 to 14 mm and in length from
10 to 20 cm, and 12 microcoils that were 6 mm
in diameter and 6 cm long.
AJR:180, March 2003
 Embolization of the Patent Ductus Venosus

A B
American Journal of Roentgenology 2003.180:716-718.

C D E

Fig. 1.—45-year-old woman with patent ductus venosus.

A and B, Contiguous contrast-enhanced CT scans with 10-mm slice thickness reveal abnormal vein (arrow, A) connecting large left portal vein to inferior vena cava through
fissure for ligamentum venosum.
C, Portogram obtained through superior mesenteric artery reveals abnormal vein (arrow) following dilated left portal vein and narrow right portal vein. Shunt near umbilical
portion of left portal vein appears to be aneurysmal.
D, Radiographic fluorogram shows transcatheter embolization using detachable microcoils and temporary balloon occlusion. Note inflated balloon (arrows).
E, Arterial portogram obtained 3 months after treatment reveals shunt to be completely occluded and portal vein branches to be normally wide.

Before the occlusion balloon was completely
deflated, the shunt venous pressure measured
through the balloon catheter was decreased by
approximately 0–3 mm Hg, and no coil migra-
tion or movement was seen during slight defla-
tion of the balloon. The temporary occlusion
balloon had been inflated for 3 hr by the time
the embolization was completed. An arterial
portogram obtained after embolization showed
that the shunt was completely occluded, and the
right portal branches were wider than before
embolization. Ten days after embolization, the
blood ammonia level had dropped from 193 to
55 µg/dL, which is in the normal range. Three
months after the intervention, an arterial porto-
gram revealed a normal portal vein and occlu-
sion of the abnormal vein (Fig. 1E). Four years
after embolization was performed, the patient’s
symptoms had not recurred.
Discussion
The ductus venosus is a fetal circulation
system that provides a direct connection be-
tween the portal vein and inferior vena cava or
left hepatic vein. A patent ductus venosus
should differ from intrahepatic portosystemic
venous shunts without liver cirrhosis, which
may be congenital in origin [7]. In the embryo,
when remnants of anastomosis between the
subcardinal venous and vitelline venous sys-
tems are present, intrahepatic portosystemic
venous shunts occur, usually between intrahe-
patic portal veins and peripheral hepatic veins.
In our patient, the abnormal vein con-
nected the umbilical portion of the portal
vein and the inferior vena cava directly
through the fissure for the ligamentum veno-
sum. The portal vein at the umbilical portion
connects with the umbilical vein and ductus
venosus in fetal circulation. According to
Mitchell et al. [1], the ductus venosus is rap-
idly obliterated after birth and forms the liga-
ment venosum. Unlike the umbilical vein,
the ductus venosus rarely reopens in patients
with portal hypertension because the ductal–
portal junction closes early, whereas the um-
bilical–portal junction is frequently patent
after birth. Our patient had a portal venous
pressure of 18 mm Hg, but portal hyperten-
sion did not seem to have caused the ductus
venosus to reopen because other collateral
veins or splenomegaly was absent and be-
cause the abnormal vein was a patent ductus
venosus, not a reopened one.
A patent ductus venosus is important to rec-
ognize because it causes portosystemic en-
cephalopathy during childhood. However,
only nine cases in adults have been reported

AJR:180, March 2003 717


[5, 6]. Why portosystemic encephalopathy of-
ten develops later in life—even when the shunt
itself is congenital—is not known [2]. A patent
ductus venosus with mild symptoms of porto-
systemic encephalopathy or heart failure may
be conservatively treated. When these symp-
toms are not conservatively controlled, the
shunt must be closed by surgical banding or
transcatheter procedures. Only three reports
about transcatheter procedures for treatment of
patients with this disease, including one adult,
appear in the literature [3, 4, 6]. Two of these
reports describe embolizations, and the other
describes placement of a reduction stent to de-
crease shunt volume.
Embolization can be expected to have the
same effect as surgical banding, but emboliza-
tion is less invasive. Liver congestion leading to
portal thrombosis has been reported to occur in
patients treated with surgical banding [1, 9], and
embolization may have the same risk. To evalu-
American Journal of Roentgenology 2003.180:716-718.
ate the risk, we measured the portal venous
pressure and performed arterial portography un-
der temporary balloon occlusion of the shunt
before embolization. The patient’s portal
venous pressure was minimally elevated, and
arterial portography revealed good blood flow
and wide right portal branches. These findings
might suggest that portal venous congestion
718
Araki et al.
would not occur after embolization. Liver bi-
opsy was not performed in our patient, but con-
firmation of the absence of liver cirrhosis by
biopsy might provide a more accurate progno-
sis. On the other hand, placement of a reduction
stent can gradually occlude the shunt. Liver
congestion may occur to a lesser extent with
stent placement than with embolization. Never-
theless, shunt flow still poses the risk of pulmo-
nary thrombosis, and one cannot predict when
the shunt will be completely occluded.
We performed embolization through the ret-
rograde transcaval route. During embolization,
temporary balloon occlusion of the patent duc-
tus venosus prevented migration of the coils as
a result of the high shunt flow. In another
study, temporary balloon occlusion reduced
the likelihood of coil migration and predicted
portal hemodynamic changes after occlusion
[6]. We believe transcatheter intervention
through retrograde transcaval access to be the
treatment of choice for patients with symptom-
atic patent ductus venosus.
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