Upper cavo‐pulmonary anastomosis by transcatheter technique

Abstract

Objectives: The aim of this animal study was to establish a shunt connection between superior vena cava (SVC) and right pulmonary artery (RPA) by transvascular intervention solely. Background: After initial shunt creation, the establishment of the upper cavo‐pulmonary anastomosis (UCPA) is the second out of three open chest operations young infants with univentricular anatomy are subjected to. To avoid the risks of reoperation with cardiovascular bypass, we sought to replace this surgical step by an interventional technique. Methods: After cannulation of jugular and femoral veins in four piglets (mean body weight of 12.5 kg) an UCPA was created by radiofrequency perforation from the SVC across the right atrium into the RPA and subsequent implantation of covered stents. The perforation was guided by biplane fluoroscopy and the perforation wire premounted with a coaxial catheter was advanced into the distal pulmonary artery and exchanged for a stiffer wire. A long sheath was brought into the RPA and an 80 mm long expanded poly‐tetra‐fluoro‐ethylene (ePTFE)‐covered Cheatham Platinum stent was then implanted connecting the SVC with the RPA. Results: Immediate angiography showed antegrade flow from SVC to RPA. Angiographic re‐evaluation after a median period of 4 weeks showed partial in‐stent stenosis but patent lumina. Additionally, veno‐venous collaterals from the SVC to the right atrium had developed. Histology of the explanted stents revealed parietal thrombi and mild to moderate pseudo intima proliferation inside the lumina. Conclusions: The transvascular creation of an upper unidirectional cavo‐pulmonary anastomosis in piglets is technically feasible using standard catheterization equipment. © 2012 Wiley Periodicals, Inc.

Transcatheter creation of bidirectional cavopulmonary connections by needle punctures in two patients

“…In previous animal experiences and in the first human case, the perforation of the vessels had been performed by high‐energy application to a perforation wire. The wire has to be placed and stabilized by a guiding catheter.…”

“…Surgical therapy to relieve congestion at right atrial level was declined by the surgical team due to multiple Fontan‐related comorbidities. After an interdisciplinary case conference, it was decided to offer the patient a transcatheter cavopulmonary connection . After thorough explanation of the particularity of the procedure, the patient gave his informed consent.…”

First-in-Human Closed-Chest Transcatheter Superior Cavopulmonary Anastomosis

“…Our group and others have explored numerous related preclinical approaches to endovascular bypass over the past decade (12,13,23). The vessel-to-vessel crossing technique was first described by our group (14).…”

“…In animals, our group and others have used needle (12) and radiofrequency perforation (23) for unidirectional “classic” Glenn shunts (SVC solely to the right PA) and more recently the contemporary, and more technically demanding, bidirectional (both PAs) version (13). In post-operative Fontan patient case reports, small pulmonary artery-to-atria fenestrations (24) and medium-sized PA reconnections (25) have been created.…”

Magnetic Resonance Imaging–Guided Transcatheter Cavopulmonary Shunt

“…Levi et al (11) used x-ray transseptal needle puncture (from the superior vena cava) aimed at prepositioned pulmonary artery angioplasty balloon “targets” to establish right-sided unidirectional Glenn circulation in 2 animals. Similarly, Schmitt et al (15) used radiofrequency energy to traverse tissue into balloon catheter targets pre-positioned in the right pulmonary artery and establish right-sided, unidirectional Glenn shunts. Although snare or balloon targets are easily positioned into the pulmonary artery in normal anatomy, for clinical translation, such targets would have to be delivered through small shunts (Blalock-Taussig or Sano) or pulmonary artery obstructions (subvalvular/valvular/supravalvular stenosis or surgical pulmonary artery bands).…”