Ann Thorac Surg 1997;64:847-849
© 1997 The Society of Thoracic Surgeons
Case Report
Use of Internal Thoracic Artery as a Systemic–Pulmonary Artery Shunt
Seiya Kikuchi, MD,
Ryuji Kashino, MD,
Tomio Abe, MD
Department of Cardiovascular Surgery, Hokkaido Children's Hospital and Medical Center, Otaru, Japan
Accepted for publication April 25, 1997.
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Abstract
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Numerous technical and physiologic problems have been described with conventional systemic–pulmonary artery shunts. We report the case of a 1-year-old girl in whom the internal thoracic artery was used to create a systemic–pulmonary artery shunt after the failure of a previous Blalock-Taussig shunt. The internal thoracic artery as an alternative systemic–pulmonary artery shunt may offer several potential advantages and can be used successfully to improve cyanotic heart disease in selected cases.
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Introduction
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A number of conventional systemic–pulmonary artery shunts have been described since Blalock and Taussig's subclavian artery–pulmonary artery anastomosis in 1945 [1]. However, some technical and physiologic problems have been described with conventional shunts. The use of the internal thoracic artery as a systemic–pulmonary artery shunt was first reported by Cobanoglu and co-workers in 1984 [2]. The internal thoracic artery for use in a shunt graft may have some advantages. This report describes the use of the internal thoracic artery as a systemic–pulmonary artery shunt in the second palliation of a 1-year-old child with transposition of the great arteries, severe pulmonary stenosis, and ventricular septal defect.
A female newborn was admitted to Hokkaido Children's Hospital and Medical Center because of cyanosis. Cardiac catheterization revealed transposition of the great arteries, severe pulmonary stenosis, ventricular septal defect, and a small patent ductus arteriosus. A left classic Blalock-Taussig shunt was performed at 5 days of age. The patient was evaluated at 3 months of age because of progressive cyanosis. Angiography demonstrated anastomotic stenosis, diffuse narrowing of the Blalock-Taussig shunt, and an underdeveloped left pulmonary artery. Percutaneous balloon angioplasty for the stenosed shunt and the underdeveloped left pulmonary artery was successfully performed.
She was reevaluated at 1 year of age because of a recurrence of deep cyanosis. Angiocardiography revealed restenosis of the previous Blalock-Taussig shunt and a small and hypoperfused left pulmonary artery (Fig 1A
). The cause of underdevelopment and hypoperfusion of the left pulmonary artery was considered to be that the blood flow of the left pulmonary artery was extremely diminished because of the unfavorable direction of the shunt flow and the development of collateral vessels in the left lung. Aortography revealed a well-developed right internal thoracic artery (RITA) (Fig 1B).
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Fig 1. . (A) Injection of contrast material into the left subclavian artery outlines the stenosed left Blalock-Taussig shunt and the right pulmonary artery. The left pulmonary artery is small and hypoperfused. (B) Injection of contrast material into the aortic arch outlines the right internal thoracic artery (arrows), which is well developed. (C) Angiogram taken 2 years postoperatively. Pulmonary arteries and the right internal thoracic artery shunt are well developed compared with preoperative sizes. The diameters of the right pulmonary artery, the left pulmonary artery, and the right internal thoracic artery have increased from 8, 5, and 4 mm to 10, 6, and 6.5 mm, respectively.
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One month after the reevaluation, she underwent a repeat palliation. During exploration through a right thoracotomy, the well-developed RITA was noted to be 4 mm in diameter, approximately the same size as the distal subclavian artery. The RITA was mobilized as long as possible and all side branches were ligated using a technique similar to that used in preparation of the internal thoracic artery for myocardial revascularization. An end-to-side anastomosis was performed with 7-0 monofilament polydioxanone suture. The RITA pedicle was sufficiently long to allow a tension-free anastomosis without kinking.
Postoperatively, her clinical state improved with a decrease in cyanosis and an increase in exercise tolerance. Two years postoperatively, angiocardiography demonstrated a large RITA 6 mm in diameter and sufficient development of the pulmonary artery to allow a Rastelli procedure (Fig 1C
). The developments of the RITA and the right and left pulmonary arteries and the increase in pulmonary artery index [3] are shown in Table 1.
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Table 1. . Changes in Diameters of Pulmonary Arteries and Right Internal Thoracic Artery and Pulmonary Artery Index
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Comment
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The need for shunt operations has decreased with the increasing number of total corrections of complex cyanotic heart defects in infancy and early childhood. However, shunts are still necessary for some complex cyanotic heart defects that are not correctable or in early infancy. Numerous technical and physiologic problems have been described with classic systemic–pulmonary artery shunts and shunts with prosthetic grafts. Recently, the use of the internal thoracic artery for an alternative systemic–pulmonary shunt has been reported with some excellent advantages [2, 4, 5]. This technique offers all the advantages of the classic Blalock-Taussig shunt [6, 7]: the natural graft, excellent long-term patency, its lower risk of congestive heart failure and pulmonary hypertension, elimination of prosthetic graft infection, and harmonious development of the pulmonary artery during the patient's growth. Furthermore, in comparison with the Blalock-Taussig shunt, growth of the arm is not affected because use of the internal thoracic artery preserves normal brachial arterial flow [4]. The anatomy of the internal thoracic artery is more suitable than that of the subclavian artery for a tension-free anastomosis to the pulmonary artery [4, 5]. The internal thoracic artery is as pliable as the subclavian artery and long enough to prevent not only stretching and kinking of itself but also distortion of the pulmonary artery [4].
Our experience, as shown in Table 1, and that of Sievers and co-workers [4] show that the internal thoracic artery as a shunt has the potential to both promote diminutive pulmonary arterial growth and facilitate the growth of the shunt itself. Although the internal thoracic artery has some distinct advantages, it has so far been uncommon to find an internal thoracic artery that is large enough to use as a shunt. The internal thoracic artery may occasionally develop as one of the collateral vessels in cyanotic children with extremely diminished pulmonary blood flow.
We believe that this technique not only can be used for primary palliation but also can be a good option for the palliation of cyanotic congenital heart defects that currently can not be surgically corrected, if an internal thoracic artery is available for a shunt.
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Footnotes
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Address reprint requests to Dr Kikuchi, Department of Cardiovascular Surgery, Hokkaido Children's Hospital and Medical Center, Zenibako 1-10-1, Otaru, Hokkaido 047-02, Japan.
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References
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- Blalock A, Taussig H. The surgical treatment of malformations of the heart. JAMA 1945;128:189–202.
- Cobanoglu A, Abbruzzese P, Brauner D, Ferre B, Issenberg H, Starr A. Therapeutic considerations in congenital absence of the right pulmonary artery. Use of internal mammary artery as a preparatory shunt. J Cardiovasc Surg 1984;25:241–5.[Medline]
- Nakata S, Imai Y, Takanashi Y, et al. A new method for the quantitative standardization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased pulmonary blood flow. J Thorac Cardiovasc Surg 1984;88:610–9.
- Sievers HH, Lange PE, Heintzen PH, Bernhard A. Internal mammary artery as a palliative systemic–pulmonary shunt in order to develop diminutive pulmonary arteries. Thorac Cardiovasc Surg 1985;33:51–2.[Medline]
- Longaker MT, Merrick S, Crombleholme TM, Langer JC, Verrier ED, Turley K. Systemic-to-pulmonary artery shunt using the internal mammary artery. Ann Thorac Surg 1989;47:464–5.[Abstract]
- Guyton RA, Owens JE, Waumett JD, Dooley KJ, Hatcher CR Jr, Williams WH. The Blalock-Taussig shunt: low risk, effective palliation, and pulmonary artery growth. J Thorac Cardiovasc Surg 1983;85:917–22.[Abstract]
- Moulton AL, Brenner JI, Ringel R, et al. Classic versus modified Blalock-Taussig shunts in neonates and infants. Circulation 1985;72(Suppl 2):35–44.
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Abstract
Introduction
