Balanced Hepatic Venous Flow with Hepatic to Azygos Vein Shunt Following the Kawashima Procedure

Objectives: Ensuring balanced hepatic venous (HV) flow to both lungs is vital for preventing pulmonary arteriovenous malformations (PAVMs) after the Kawashima procedure in patients with polysplenia and interrupted inferior vena cava. This study investigated the long-term distribution of HV flow following two Fontan completion methods: HV-to-azygos vein shunt (HVAZ) and HV-to-pulmonary artery shunt (HVPA). Methods: We retrospectively reviewed 20 patients who underwent Fontan completion after the Kawashima procedure between 2004 and 2021 (HVAZ, n = 10; HVPA, n = 10). HV flow distribution was assessed by angiography (balanced/partly unbalanced/completely unilateral). For long-term analysis, patients were grouped according to final HV configuration, including those who required shunt conversion after initial Fontan completion. Group comparisons used Fisher's exact and Mann-Whitney tests. Results: Balanced HV flow was observed in 7/9 patients with HVAZ morphology compared with 1/10 with HVPA (P = .006). In the bilateral superior vena cava (SVC) subset, 6/7 with HVAZ had balanced flow versus none with HVPA (P = .005). Median follow-up was 9.2 years, during which final oxygen saturation (91% vs. 95%, P = .39) and reintervention rates were comparable between groups, although the timing and underlying causes of reinterventions differed. Conclusions: HVAZ was associated with more balanced HV flow than HVPA, including patients with bilateral SVCs. Long-term outcomes such as oxygen saturation were comparable, suggesting that HVAZ may represent a physiologically advantageous option for Fontan completion in patients with complex venous anatomy.