Asian Cardiovasc Thorac Ann 2005;13:274-276
© 2005 Asia Publishing EXchange Ltd
Stent Implantation to Maintain Patency of A Stenosed Blalock Taussig Shunt
Amjad Kouatli, MD,
Jameel Al-Ata, MD,
M Omar Galal, PhD,
Muhammed A Amin, FCPS,
Arif Hussain, MD
Section of Pediatric Cardiology, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
For reprint information contact: M Omar Galal, PhD Tel: 966 2 667 7777 Fax: 966 2 663 9581 Email: ogalal{at}yahoo.com, Cardiovascular Department, MBC J 16, King Faisal Specialist Hospital and Research Centre, P.O. Box 40047, Jeddah 21499, Saudi Arabia.
 |
ABSTRACT
|
|---|
A 14-year-old female with complex congenital heart disease underwent a left-sided classical Blalock Taussig (BT) shunt 15 days after birth. Ten years after the operation her oxygen saturation had decreased significantly. An angiography revealed a severely stenosed BT shunt. Balloon dilation including implantation of a 6 x 13 mm stent was performed successfully. Immediately after intervention, oxygen saturation rose from 55% to 80 84% in room air. Follow-up at a year and a half later showed the classical BT shunt was still patent.
|
INTRODUCTION
|
|---|
Balloon dilations of stenosed or totally occluded modified or classical Blalock Taussig (BT) shunts have been performed with variable results.1–8 There are rare reports describing balloon dilation of such shunts 10 years after surgery.4 Our report shows successful balloon dilation and stent implantation of a nearly-occluded 5 mm in diameter classical BT shunt established 10 years earlier.
|
CASE REPORT
|
|---|
The subject was a 14-year-old female born with abdominal and atrial situs ambiguous, interrupted inferior vena cava, single atrium, unbalanced atrioventricular septal defect, moderate common atrioventricular valve regurgitation, dextro transposed great arteries, pulmonary atresia, right aortic arch, and multiple small aorto-pulmonary collaterals arising from the right subclavian artery. At 15 days of age, on April 9, 1991, she underwent a left classical BT shunt operation. On two previous cardiac catheterizations (1994, 1997) performed at another institution, a right pulmonary artery was not visible. She was judged a high-risk candidate for any further surgical repair. Over the last few years she had become severely cyanosed with oxygen saturation down to 55% in room air leading to severe limitation in physical activity. At this time she could only walk a few steps before she was wheelchair bound. We catheterized her to assess hemodynamics and to evaluate the previously placed BT shunt, in view of balloon dilation and stent implantation. At the time of cardiac catheterization on Nov 5, 2001, she weighed 35 kg and was 146 cm in height, blood pressure from the right arm was 96/63 mm Hg and heart rate was 100 beats·min–1. Oxygen saturation before catheterization was 55% in room air.
After sedation with intravenous fentanyl and midazolam, vascular access was obtained through the right femoral artery and right femoral vein using 6F sheaths. Angiograms were performed in the aortic arch as well as in the left subclavian artery using a 6F pigtail catheter, which revealed an interrupted right pulmonary artery from the main pulmonary artery. The intrapericardial segment of the right pulmonary artery was absent. Only the distal segment of the right pulmonary artery at the level of the right hilum could be seen. There were multiple aorto-pulmonary collaterals arising from the right subclavian artery supplying the distal right pulmonary artery. The left pulmonary artery was partially filled with the BT shunt. The classical BT shunt was diffusely narrow with additional stenosis at its center, measuring only 2 mm in diameter (Figure 1A
). The total length was 13 mm. After crossing the classical BT shunt with 5F Judkins right catheter, 0.014 inch PTCA wire was passed through it. The regular sheath was exchanged for a 6F long Mullins sheath over the wire. Then a 6 x 13 mm premounted stent (Johnson & Johnson, Roden, Netherland) was advanced and positioned in the BT shunt and was successfully deployed (Figure 1B). Subsequent pulse oximetry revealed that oxygen saturation had improved from 55% to 80 84% in room air. A final angiogram done through the Mullins sheath after deployment of the stent revealed a widely patent BT shunt while an echocardiagram showed a patent BT shunt with continuous flow across it in a peak systolic velocity exceeding 4 m·sec–1 (Figure 2). The patient was heparinised, initially with multiple doses during the procedure and then was kept on continuous infusion at a dosage of 15 IU·kg·hr–1 for the next 24 hours. She was discharged on aspirin, 100 mg·day– 1. A month and a half later, she was able to walk and was no longer wheelchair bound. Follow-up at a year and a half later revealed that the classical BT shunt was still patent.
View larger version (103K):
[in this window]
[in a new window]
|
Figure 1A. Aortic angiogram in AP view at the mouth of the previous Blalock Taussig shunt with almost complete occlusion.
|
|
View larger version (97K):
[in this window]
[in a new window]
|
Figure 1B. Aortic angiogram in AP view at the mouth of the previous Blalock Taussig shunt immediately following the successful positioning of a 6-by-13-mm premounted stent in the Blalock Taussig shunt.
|
|
|
DISCUSSION
|
|---|
Although balloon dilation of stenosed or completely occluded BT shunts has been performed since 1985,5 it remains an uncommon procedure. It has been shown that modified as well as classical BT shunts can be ballooned to achieve patency with good efficacy and a low rate of complications. While early occlusion of a BT shunt after surgery can be expected to respond readily to balloon dilation, it is not assumed that a calcified BT shunt would respond easily to balloon dilation, although a case report from Turkey suggested this.4 In our case, the patient was status post left classical BT shunt 10 years before, and was declared not amenable to any further surgery. We therefore elected to perform a stent implantation of the BT shunt as a final palliative intervention and to ensure that the shunt would remain open. Stenting of the PDA has been shown only recently by different authors to be a relatively safe procedure.
There are rare reports in the literature discussing stent implantation in BT shunts.6–7 We believe that in the case of a long standing BT shunt, whether classical or modified, a stent implantation is a better option for maintaining patency than balloon dilatation. We suggest this because there is an increased risk of calcification in the case of a long standing modified BT shunt. It can be demonstrated that the procedure is made more safe and effective due to the availability of premounted stents. A year and a half after the procedure, the stent was still patent and there was no stenosis secondary to possible intimal proliferation, which has been described as a potential risk of this procedure. We conclude that stent implantation of a classical BT shunt can be performed with minor complications. However, the long-term effects of such a procedure are yet to be evaluated.
|
REFERENCES
|
|---|
- Qureshi SA, Martin RP, Dickinson DF, Hunter S. Balloon dilatation of stenosed Blalock-Taussig shunts. Br Heart J 1989;61:432–4.[Abstract/Free Full Text]
- Marks LA, Mehta AV, Marangi D. Percutaneous transluminal balloon angioplasty of stenotic standard Blalock-Taussig shunts: effect on choice of initial palliation in cyanotic congenital heart disease. J Am Coll Cardiol 1991;18:546–51.[Abstract]
- Galal O, Qureshi SA. Balloon dilation recanalization of completely occluded modified Blalock-Taussig shunt. Cardiol Young 1994;4:17880.
- Saltik IL, Guler-Eroglu A, Sarioglu A, Batmaz G. Balloon dilatation angioplasty of a stenotic Blalock-Taussig anastomosis. A case report. Turk J Pediatr 1996;38:515–9.[Medline]
- Fischer DR, Park SC, Neches WH, Beerman LB, Fricker FJ, Mathews RA, et al. Successful dilatation of a stenotic Blalock-Taussig anastomosis by percutaneous transluminal balloon angioplasty. Am J Cardiol 1985;55:861–2.[Medline]
- El-Said HG, Clapp S, Fagan TE, Conwell J, Nihill MR. Stenting of stenosed aortopulmonary collaterals and shunts for palliation of pulmonary atresia/ventricular septal defect. Catheter Cardiovasc Interv 2000;49:430–6.[Medline]
- Peuster M, Fink C, Bertram H, Paul T, Hausdorf G. Transcatheter recanalization and subsequent stent implantation for the treatment of early postoperative thrombosis of modified Blalock-Taussig shunts in two children. Cathet Cardiovasc Diagn 1998;45:4058.
- Galal MO, Attas K, Baslaim G. Recanalization of an occluded modified Blalock-Taussig shunt by balloon angioplasty within 12 hours of its construction. Cardiol Young 2000;10:641–3.[Medline]
TOP
ABSTRACT
INTRODUCTION
