Asian Cardiovasc Thorac Ann 1998;6:320-322
© 1998 Asia Publishing EXchange Pte Ltd
Percutaneous Closure of Aortopulmonary Collateral for Postoperative Hemoptysis
Vijit Koshy Cherian, MS,
Arun Kumar Gupta, MD1,
Soman Rema Krishna Manohar, MCh
Department of Cardiovascular & Thoracic Surgery
1 Department of Radiology Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram, India
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For reprint information contact: Soman Rema Krishna Manohar, MCh Department of Cardiovascular & Thoracic Surgery Sree Chitra Tirunal Institute for Medical Sciences and  Technology Thiruvananthapuram 695011, India Tel:91 471 44 3152 Fax:91 471 44 6433 Email:sctimst{at}renback.delhi.nic.in
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ABSTRACT
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A 30-year-old male with tetralogy of Fallot presented with a history of hemoptysis. He had a major aortopulmonary collateral artery that could not be interrupted during corrective surgery due to technical problems. Postoperative recovery was complicated by congestive heart failure. Embolization of the aortopulmonary collateral artery was planned but he developed massive hemoptysis and emergency transcatheter occlusion was performed, which successfully controlled both hemoptysis and congestive heart failure.
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INTRODUCTION
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A major aortopulmonary collateral artery (MAPCA) presents a challenge in the surgical correction of patients with severe pulmonary stenosis or atresia. Embolization of the MAPCA in the management of hemoptysis has shown good results. We report a rare presentation of postoperative hemoptysis due to MAPCA in an adult who underwent intracardiac repair of tetralogy of Fallot.
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CASE REPORT
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A 30-year-old male, diagnosed to have tetralogy of Fallot without restrictive symptoms since early childhood experienced episodes of hemoptysis for which he was investigated. He had central cyanosis, clubbing, and mild icterus. His hemogram showed a hemoglobin level of 270 g·L–1 and a packed cell volume of 83%. Total serum bilirubin was 38 mg·L–1 and he was diagnosed to have congenital hyperbilirubinemia. Cardiac catheterization confirmed the diagnosis of tetralogy of Fallot with systemic desaturation (75%), systemic right ventricular pressures with a right ventricular outflow gradient of 110 mm Hg, a large single subaortic ventricular septal defect, aortic overriding, and fair-sized pulmonary arteries (McGoon index 1.8). There was a large aortopulmonary collateral artery arising from the upper descending thoracic aorta supplying both lungs. Since there was no patent ductus, preoperative embolization of the MAPCA was not considered for fear of aggravation of hypoxia.
During corrective surgery, ligation of the MAPCA was attempted but due to dense pleural adhesions, dissection in the perihilar and posterior mediastinum was not feasible. Infundibular resection, Dacron patch closure of the ventricular septal defect, and pericardial transannular patch reconstruction of the right ventricular outflow tract were performed. The patient was easily weaned off cardiopulmonary bypass and was extubated the next day. However, he showed features of congestive heart failure later in the postoperative period and required anti-failure measures and inotropic support. Postoperative echocardiography showed no residual defects and good ventricular function. He showed initial improvement but during the 2nd week, his heart failure worsened and he required more inotropic support. Therefore, a hemodynamic study and catheter embolization of the MAPCA were planned. While preparations were being made, he developed an episode of massive hemoptysis on the 15th postoperative day.
Emergency digital subtraction angiography showed the branch of the MAPCA supplying the right lung to be the source of the hemoptysis (Figures 1A and 1B
). Transcatheter embolization of the MAPCA was attempted with hydrogel particles of 500 to 800 microns. Reduction in flow was noted but there was still a considerable residual flow on repeat angiography. At this point, it was decided to embolize the MAPCA by injecting enbucrilate tissue adhesive. Histoacryl (enbucrilate; B Braun, Melsungen, Germany) of 1 mL diluted with 3 mL Lipiodol (iodized poppy seed oil; Guerbet, Aulnay sous Bois, France) was injected and the MAPCA was successfully occluded (Figures 2A and 2B). As this was performed as an emergency procedure, a detailed hemodynamic study was postponed.
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Figure 1. Pre-embolization aortogram (A) and selective angiogram (B) showing a major aortopulmonary collateral artery supplying both lungs.
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Figure 2. Post-embolization aortogram (A) and cast of Histoacryl in the occluded major aortopulmonary collateral artery (B) showing no distal filling and no evidence of embolic material in the lung or pulmonary artery.
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There was no further hemoptysis, the congestive cardiac failure subsided, and the patient recovered rapidly. On follow-up at 6 months, he was asymptomatic, chest radiography showed normal lung fields, and echocardiography showed a good surgical result. Hence, a further hemodynamic study was not carried out.
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DISCUSSION
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The most common cause of hemoptysis in congenital heart disease is rupture of aortopulmonary collaterals.1 Percutaneous closure of large collateral arteries has been well-established using a Gianturco wire coil, bucrylate tissue adhesive, or silicone balloons.2–4 Although our patient had episodes of hemoptysis before surgery, preoperative occlusion was considered risky for fear of aggravation of hypoxia because the artery was large and supplied both lungs.5
Surgical ligation of the MAPCA through a median sternotomy via the pleural space through the perihilar mediastinum or through the posterior pericardium might have proved impossible due to inaccessibility. The right-pleural approach was difficult in this case due to dense perihilar adhesions and the left hemithorax was inaccessible from a sternotomy. However, our patient did not have any significant pulmonary disease in the past to account for the adhesions. A complementary lateral thoracotomy on the side of the descending thoracic aorta has been advocated in such a situation by McGoon and colleagues.6 Embolization of the MAPCA for management of hemoptysis has been reported previously.7
Since our patient was easily weaned off cardiopulmonary bypass and off the ventilator, the MAPCA was expected to regress spontaneously. In retrospect, this was not a correct assumption as an immediate postoperative embolization of the MAPCA, preferably before extubation, could have prevented both congestive cardiac failure and life-threatening hemoptysis. We would like to emphasize the importance of early interruption of a large MAPCA to avoid such complications in similar cases.
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REFERENCES
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ABSTRACT
INTRODUCTION
