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Prevalence and risk factors for aortopulmonary collateral vessels after Fontan and bidirectional Glenn procedures
J K Triedman1, N D Bridges, J E Mayer
1Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115.
Insights
Aortopulmonary collateral vessels are common after bidirectional Glenn and Fontan procedures, affecting 36% of patients. These vessels, often missed by aortograms, can impact pulmonary blood flow and oxygen saturation.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Interventional Cardiology
Background:
- Aortopulmonary collateral vessels (APCVs) are frequently observed post-bidirectional Glenn or Fontan procedures.
- These vessels can create pulmonary blood flow competitive with anterograde cavopulmonary flow.
Purpose of the Study:
- To determine the prevalence of APCVs in patients who have undergone bidirectional Glenn or Fontan procedures.
- To identify risk factors associated with the development of APCVs.
Main Methods:
- Retrospective review of 196 patients undergoing catheterization after bidirectional Glenn or Fontan procedures between 1988 and 1992.
- Analysis of clinical, hemodynamic, and angiographic data.
Main Results:
- APCVs were diagnosed in 36% of patients; more common after bidirectional Glenn (65%) than Fontan (30%) procedures.
- A history of Blalock-Taussig shunt increased the likelihood of APCVs (50% vs. 24%).
- Internal mammary arteries and thyrocervical trunks were common origins; aortograms often failed to visualize APCVs.
Conclusions:
- APCVs are prevalent following bidirectional Glenn and Fontan procedures.
- Aortograms have limitations in diagnosing APCVs, which can cause left-to-right shunting indicated by increased pulmonary artery oxygen saturation.
- The clinical significance and indications for APCV closure remain unknown.
Objectives:
The purpose of this study was to evaluate the prevalence of and risk factors for aortopulmonary collateral vessels in patients who have undergone a bidirectional Glenn or Fontan procedure, or both.
Background:
Aortopulmonary collateral vessels are frequently observed angiographically in patients after a bidirectional Glenn or Fontan procedure. These vessels may provide a source of pulmonary blood flow competitive with anterograde cavopulmonary flow.
Methods:
We performed a retrospective study of all patients (n = 196) who underwent catheterization between January 1, 1988 and February 29, 1992 (n = 268) after bidirectional Glenn or Fontan procedures and reviewed clinical, hemodynamic and angiographic phone data.
Results:
Collateral vessels were diagnosed in 36% of patients. Patients who underwent the bidirectional Glenn procedure were more likely to have collateral vessels than patients who underwent the Fontan procedure (65% vs. 30%, respectively; p < 0.0001). Patients with a history of a Blalock-Taussig shunt were more likely to have collateral vessels than those without (50% vs. 24%, respectively; p = 0.0006). Discretely identifiable collateral vessels were measurable in 54 (20%) of 268 catheterizations. The total estimated cross-sectional area of these vessels averaged 10.7 +/- 7.2 mm2. In patients who underwent the bidirectional Glenn procedure, a step-up in oxygen saturation from the superior vena cava to the distal pulmonary arteries or an upper lobe filling defect, or both, on pulmonary angiogram predicted total estimated cross-sectional area of collateral vessels. Most collateral vessels originated from the internal mammary arteries (34%) and the thyrocervical trunks (22%). Only 9% of collateral vessels arising from the brachiocephalic vessels were visualized by aortogram; the remainder required selective angiography in the subclavian or more distal arteries.
Conclusions:
Aortopulmonary collateral vessels are common after bidirectional Glenn and Fontan procedures. Aortograms often fail to diagnose their presence. The left to right shunt carried by these vessels is associated with a step-up in oxygen saturation in the distal pulmonary arteries. The clinical significance and indications for closure of these vessels are not known.