Augmentation of pulmonary blood flow with an axillary arteriovenous fistula after a cavopulmonary shunt

Abstract

Of 320 children with cyanotic congenital heart malformations who had previously undergone cavopulmonary shunt operations, 11 had increasing cyanosis and exercise intolerance and were considered unsuitable for definitive repair, a Fontan procedure, or other palliation. Eight had a previous Glenn shunt and three had a previous bidirectional cavopulmonary connection. To augment pulmonary blood flow, 10 patients underwent creation of an ipsilateral axillary arteriovenous fistula. Mean oxygen saturations were 80% +/- 2% before operation, 85% +/- 2% immediately after operation, and 84% +/- 3% at a mean follow-up interval of 7.4 years (range 0.1 to 15.5 years). Mean hemoglobin values were 202 +/- 10 gm/L before operation, 177 +/- 10 gm/L after operation, and 191 +/- 14 gm/L at latest review. The only complication was mild swelling of the arm distal to the fistula in one patient. All patients reported improvement in exercise tolerance. Eight patients have continued evidence of fistula patency. Development of ipsilateral pulmonary arteriovenous fistulas has not been observed in any patient. Creation of an axillary arteriovenous fistula to augment pulmonary blood flow after a cavopulmonary shunt provides useful palliation for complex cyanotic heart disease when other options are limited. Such additional sources of pulmonary blood flow may influence the development of pulmonary arteriovenous fistulas.

Bilateral double axillary artery: Embryological basis and clinical implications

“…Some cases of thoracic outlet syndrome require surgical decompression of the subclavian artery or even concomitant arterial reconstruction since compression of the axillary artery and its circumflex branches by the humeral head is a surprisingly common pathologic mechanism. Moreover, the incidence of iatro- genic axillary injuries has risen with the increasing use of transaxillary catheterization by cardiologists and radiologists (Eastcott, 1992;Magee et al, 1996). Thus, awareness of the presence of anomalies affords a better therapeutic approach to arterial injuries (Durham et al, 1995;Urschel, 1996) and other interventional vascular procedures.…”

Regression of Pulmonary Arteriovenous Malformations after Transcatheter Reconnection of the Pulmonary Arteries in Patients with Unidirectional Fontan

“…The stimulus for development of these lesions is the absence of a suspected “hepatic factor” 4 . This is inferred by the regression of these lesions once hepatic effluent is included in the circulation to the affected lung by heart transplant, surgical Fontan completion, or surgical creation of a brachial arteriovenous fistula 9–11 . It is also supported by the presence of PAVM in patients with liver failure and resulting “hepatopulmonary syndrome.” Surgical intervention is successful in the treatment of PAVM but carries a certain morbidity and mortality, thereby providing impetus for the development of minimally invasive percutaneous techniques for the treatment of PAVM.…”

Transcatheter Closure of a Peripheral Arteriovenous Fistula: A Unique Use of a Covered Stent in a Child with Complex Congenital Heart Disease

“…5 The prevalence was reported to be especially higher in children with laterality disorders. 6 Patients with laterality disorder postcavopulmonary anastomosis were excluded form fistula creation by Magee et al 7 because of the concern of augmenting the shunt through such atrioventricular malformations and therefore increasing cyanosis and ventricular volume overload. We did not look for arteriovenous malformations in our patient, but the fact that his cyanosis deepened after the creation of the fistula and signs of volume overload were decreased after fistula closure suggest that arteriovenous malformations in the pulmonary circulation might have played a role in the pathophysiology of the child's clinical deterioration.…”