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Systemic venous collateral development after the bidirectional cavopulmonary anastomosis

Prevalence and predictors

Alan G. Magee, MB, BCh, MRCP^* , Brian W. McCrindle, MD, MPH, FACC^* , John Mawson, MB, ChB, Lee N. Benson, MD, FACC^* , William G. Williams, MD^* and Robert M. Freedom, MD, FACC^*

^* Departments of Pediatrics, Surgery and Diagnostic Imaging, The Hospital for Sick Children and the University of Toronto Faculty of Medicine, Toronto, Canada
Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children and the University of Toronto Faculty of Medicine, Toronto, Canada
Variety Club Cardiac Catheterization Laboratories, The Hospital for Sick Children and the University of Toronto Faculty of Medicine, Toronto, Canada

View larger version (184K): [in a new window]   Figure 1 Patient with double outlet right ventricle, multiple ventricular septal defects, and a straddling right atrioventricular valve who underwent a BCPA at 1 year of age. A) A preoperative left brachiocephalic vein injection is shown in the frontal projection. There is a good-sized right superior vena cava (SVC) and filling of a tiny superior intercostal vein (arrow). Postoperative left SVC injection (LSVC) can be seen in the frontal (B) and lateral (C) projections. An enlarged LSVC is now seen connecting to coronary sinus (CoS) with areas of dilatation and narrowing. The SVC was ligated at the time of Fontan completion.

View larger version (152K): [in a new window]   Figure 2 Balloon occlusion angiogram in the right pulmonary artery (RPA), frontal projection, filling the left pulmonary artery (LPA) and BCPA. The patient had a univentricular connection of the right ventricular type. The BCPA is widely patent. A dilated pericardial vein (arrow) courses anteriorly to enter the inferior vena cava.

View larger version (64K): [in a new window]   Figure 3 Postoperative right BCPA, right SVC injection, frontal (A) and lateral (B) projections. The SVC decompresses down a channel that in A has a similar appearance to an azygous vein. B) The anterior position of the internal mammary vein.

View larger version (83K): [in a new window]   Figure 4 A patient with dextrocardia and left atrial isomerism, azygous continuation of the right SVC, with left SVC draining to coronary sinus. A) After a BCPA, a balloon occlusion angiogram in the frontal projection is performed within the azygous vein (AZY) showing filling of a paravertebral plexus of veins (*). B) After deflating the balloon and advancing the catheter to the left renal vein (LRV), contrast enters a collateral channel (arrow) and hence (*) to portal vein (PV). The liver parenchyma drains via the hepatic veins to the common atrium. This child was profoundly cyanosed with an aortic oxygen saturation of 65% in 100% oxygen. Coil occlusion of the LRV-PV connection was performed with improvement in O2 saturation to 80% in air.