Successful thrombolytic therapy for acute massive pulmonary thrombosis after total cavo-pulmonary shunt

A 4-year-old boy with massive pulmonary thrombosis after total cavo-pulmonary shunt was successfully treated by aggressive thrombolytic therapy. In the unique circulation involving total cavo-pulmonary shunt with azygous connection, the clinical manifestations of pulmonary thrombosis are somewhat different from those observed with ordinary biventricular circulation. The patient's hemodynamic state, including central venous pressure and systemic blood pressure, was relatively stable, but there was a dramatic decrease in oxygenation, possibly because azygous continuation allowed reversed blood flow from the superior vena cava to return to the atrium through collateral vessels between the azygous vein and the portal vein. Clinicians should be aware of this complication and unique circulation, and the importance of prompt diagnosis cannot be overemphasize. The effectiveness of the aggressive thrombolytic therapy in this case was noteworthy.