Ann Thorac Surg 2005;79:1754-1755
© 2005 The Society of Thoracic Surgeons
Case report
Covered Stent Treatment of Right Pulmonary Artery Stenosis and Waterston Shunt
Ingo Daehnert, MD*,a,
Michael Wiener, MDa,
Martin Kostelka, MDa
a Departments of Pediatric Cardiac Surgery and Pediatric Cardiology, Heart Center, University of Leipzig, Leipzig, Germany
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Daehnert, Department of Pediatric Cardiology, Heart Center, University of Leipzig, Struempellstr 39, Leipzig 04289, Germany
ingodaehnert{at}yahoo.de
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Abstract
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A 35-year-old man with residual Waterston shunt and concomitant right pulmonary artery stenosis after mutiple surgery for tetralogy of Fallot presented with significant left to right shunt and left heart failure. We describe the percutaneous placement of an endovascular stent graft to occlude the Waterston shunt and relieve the right pulmonary artery stenosis simultaneously. This novel use of a covered stent effectively treated a residual problem without reoperative thoracotomy.
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Introduction
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Direct anastomosis of the ascending aorta to the right pulmonary artery, the so-called Waterston shunt, was undertaken as a palliative procedure for children with cyanotic congenital heart disease due to obstruction of the pulmonary outflow tract with reduced pulmonary blood flow. Many complications of this shunt have been documented, among others are right pulmonary artery stenosis, side different pulmonary perfusion, and endocarditis [1, 2].
Stent mounted endovascular grafts, so-called covered stents, have recently found widespread use in aortic and peripheral angiologic interventional procedures; their use in coronary diseases is under investigation [3]. So far there are only a few reports about the use of covered stents in congenital heart disease and its sequelae [4–6].
A 35-year-old man presented to our institution in mild left ventricular failure for reevaluation. He had had a Waterston shunt for palliation of tetralogy of Fallot at 2 years of age. Bacterial endocarditis had been treated medically over a 6-month period at 12 years of age. He underwent corrective surgery including a transanular patch at 16 years of age. A valved conduit was implanted in the pulmonary position and the tricuspid valve was reconstructed because of pulmonary regurgitation and right ventricular failure at 34 years of age. The patent Waterston shunt and a concomitant right pulmonary artery stenosis were diagnosed by echocardiography and were confirmed by cardiac catheterization. The Waterston shunt had a diameter of 5 mm with systolic-diastolic left to right shunt to the right pulmonary artery (Fig 1). The right pulmonary artery had a proximal diameter of 12 mm with the narrowest point located directly adjactant to the shunt with a diameter of 6 mm (Fig 2). The left to right shunt was calculated oxymetrically to be 45% of pulmonary blood flow. Left ventricular end-diastolic pressure (16 mm Hg), pulmonary capillary wedge pressure (16 mm Hg), and pulmonary artery pressure (45/14; mean, 25 mm Hg) were elevated. The patient's previous surgical procedures were believed to have increased the risk of surgical repair of the Waterston shunt and right pulmonary artery stenosis. Therefore, the decision was made to proceed with percutaneous implantation of an endovascular balloon dilatable stent graft into the right pulmonary artery. Informed consent was obtained from the patient. A 12 mm x 38 mm Jomed covered stent graft (Jomed International AB, Helsingborg, Sweden) mounted on a 12 mm x 40 mm high pressure balloon catheter was implanted. After implantation, there was no residual shunt and there was a residual gradient of 10 mm Hg between the proximal and distal right pulmonary artery (Figs 3, 4). The procedure was well tolerated, and the patient was discharged 48 hours later. Signs and symptoms of the left heart failure disappeared. Re-catheterization 6 months later showed neither re-canalization of the shunt nor right pulmonary re-stenosis. Pressure values of the pulmonary arteries, the pulmonary capillary wedge, and the left ventricle were normal.
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Fig 1. Frontal angiogram of the distal right pulmonary artery. Contrast is injected into an arterial pigtail catheter crossing the patent Waterston shunt (arrow) from the ascending aorta (Ao) to the right pulmonary artery (RPA). The tip of a second catheter introduced antegradely is in the main pulmonary artery.
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Fig 2. Frontal angiogram of simultaneous contrast injection to the proximal (PA) and distal right pulmonary artery (RPA) defining the stenosis (*). One pigtail catheter crosses the Waterston shunt from the aorta and another comes from the venous access.
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Fig 3. The frontal pulmonary angiogram shows the stent in place (arrows) dilating the right pulmonary artery and occluding the Waterston shunt.
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Fig 4. The lateral aortogram (Ao) shows a contrast-free stent (arrow) proving complete shunt occlusion.
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Comment
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Endovascular grafts have been used for many indications including aortopulmonary fistulas [5], patent ductus arteriosus [6], pulmonary artery pseudoaneurysm [7], and aortic, iliac, and femoral aneurysms. The use in a combined lesion of native aortic coarctation and patent ductus arteriosus was recently reported [8]. This patient presented after three previous operations and bacterial endocarditis. Considering the history, size, and site of the lesion, an interventional approach seemed very attractive: An endovascular stent graft allowing for simultaneous closure of the shunt and relief of the adjacent pulmonary artery stenosis. As compared with the potential surgical alternative, this approach appeared to be simple and safe to us. In fact, this approach proved to be a fast and very smooth procedure. However, the results have to be followed closely, because the long-term fate of these stent grafts is not yet known.
This case represents a novel use of an endovascular stent graft. Newer devices for minimal invasive treatment may facilitate the treatment of late postoperative sequelae in selected adults with congenital heart disease.
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References
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- DeBoer A. Classics in thoracic surgery. The Waterston shunt: a commentary. Ann Thorac Surg. 1987;44:326–327[Medline]
- Hull DA, Shinebourne E, Gerlis L, Nicholson AG, Sheppard MN. Rupture of pulmonary aneurysms in association with long-standing Waterston shunts. Cardiol Young. 2001;11:123–127[Medline]
- Campbell PG, Hall JA, Harcombe AA, de Belder MA. The Jomed covered stent graft for coronary artery aneurysms and acute perforation: a successful device which needs careful deployment and may not reduce restenosis. J Invasive Cardiol. 2000;12:272–276[Medline]
- Richens T, Houston AB, Ruiz C, Wilson N. Interventional treatment of lateral tunnel dehiscence in a total cavopulmonary connection using a balloon expandable covered stent. Catheter Cardiovasc Interv. 2000;50:449–451[Medline]
- Atmeca Y, Altin T, Ozdol C, Pamir G, Caglar N, Oral D. Coronary-pulmonary artery fistula associated with right heart failure: successful closure of fistula with a graft stent. Angiology. 2002;53:613–616
- Roques F, Hennequin JL, Sanchez B, Ridarch A, Rousseau H. Aortic stent-graft for patent ductus arteriosus in adults: the aortic exclusion technique. Ann Thorac Surg. 2001;71:1708–1709[Abstract/Free Full Text]
- Hannan RL, Miyaji K, Burke RP, Zahn EM. Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm. Ann Thorac Surg. 2001;71:727–729[Abstract/Free Full Text]
- Sadiq M, Malick NH, Qureshi SA. Simultaneous treatment of native coarctation of the aorta combined with patent ductus arteriosus using a covered stent. Catheter Cardiovasc Interv. 2003;59:387–390[Medline]
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Abstract
Introduction
