Intractable Back Pain After Coil Embolization of Giant Veno-Venous Collaterals in a Patient With Fontan Circulation

Abstract

SummaryVeno-venous collaterals are sometimes seen in patients after the Fontan procedure. A 28-year-old female with tricuspid atresia who underwent the Fontan procedure had oxygen desaturation due to a giant veno-venous collateral. Coil embolization was performed for the collateral. After the procedure, she complained of severe back pain. Anti-inflammatory analgesics and steroids were not effective, although carbamazepine promptly relieved the intractable pain. Treatment-related pain after coil embolization for veno-venous collaterals in patients with Fontan physiology is quite rare, although cardiologists must recognize a critical condition to be differentiated from vascular occlusion. (Int Heart J 2017; 58: 298-301) Key words: Cardiac catheterization, Complication, Neuropathic pain, Total cavopulmonary connection T he complete caval-pulmonary repair of single ventricle lesions has created a whole new spectrum of systemic artery to pulmonary artery and systemic vein to pulmonary vein collaterals/fistulae. 1) These collaterals provide competition to the already precarious forward pulmonary blood flow, produce extra volume on the single ventricle, and/ or create a right to left shunt with systemic desaturation of the patient. 1) Therefore, when "Fontan" type patients undergo catheterization, cardiologists should check these lesions carefully and occlude if they exist. 1,2)Occlusion of vital structures/organs, embolization of unwanted areas, migration of devices, and hemolysis are wellknown complications of vascular occlusions.1) To the best of our knowledge, there are no previous reports regarding the refractory pain associated with the procedures of coil embolization for veno-venous collaterals in patients who underwent the Fontan operation.Here, we describe a 28-year-old female with Fontan physiology who developed intractable severe back pain after undergoing coil embolization for giant veno-venous collaterals. Carbamazepine successfully controlled the intractable pain although many other analgesic drugs failed to relieve it. Case ReportA female patient with tricuspid atresia (type Ic) initially underwent banding of the pulmonary arterial trunk at 6 months of age. The second operation had not been carried out until she was 5 years old, when the total cavopulmonary connection (lateral tunnel) was completed. She received coil embolization of a veno-venous collateral from the innominate vein to the left atrium for the first time when she was 12 years old. At that time, her peripheral oxygen saturation was at around 90%. She was referred to our hospital when she moved to our city at 26 years of age. Two years after the first visit to our hospital, a follow-up enhanced computed tomography (CT) revealed many veno-venous collaterals ( Figure 1A). Her peripheral oxygen saturation was 86% under room air. Hence, she was admitted to our hospital for embolization of the collaterals. On admission, she was well and her vital signs were as follows; blood pressure 110/70 mmHg; pulse rate 78/min; body temperature 36.5°C; an...

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Collaterals in congenital heart disease: when and how to treat?

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