Double trouble in tetralogy: Rare sequential pseudoaneurysms managed by distinct surgical and endovascular approaches

Pseudoaneurysm formation following a modified Blalock-Taussig-Thomas (BTT) shunt in tetralogy of Fallot (TOF) is rare, most commonly involving the subclavian artery; pulmonary artery (PA) pseudoaneurysms are even less frequent. We report an infant initially presenting with cyanosis and diagnosed with TOF, who underwent a right modified BTT shunt. She later developed hemoptysis, and imaging revealed a subclavian artery pseudoaneurysm at the shunt anastomosis, managed surgically. One year later, recurrent hemoptysis led to the diagnosis of a PA pseudoaneurysm at the distal end of the prior shunt. This was successfully treated using a novel endovascular technique adapted from aortic aneurysm repair. This rare case of sequential pseudoaneurysms - subclavian and pulmonary - highlights the importance of maintaining a high index of suspicion, utilizing early cross-sectional imaging, and applying tailored surgical or endovascular approaches to manage complex vascular complications in children with prior shunt surgeries.