Novel use of a retroaortic innominate vein in cavopulmonary anastomosis

Abstract

is well recognized. 3 We present a child with tricuspid atresia and pulmonary atresia with bifurcation stenosis of confluent pulmonary arteries (Figure 1). The child also had a right aortic arch. The parallel course of the retroaortic innominate vein with the pulmonary artery was used in pulmonary artery reconstruction by creating a wide side-to-side anastomosis (Figure 2). Clinical Summary The child was given a diagnosis of tricuspid atresia and pulmonary atresia at birth. He underwent placement of a left modified Blalock-Taussig shunt at day 1 of life. He was initially doing well, and then he presented at 6 months of life with increasing cyanosis. A central shunt from the aorta to the right pulmonary artery was placed through a sternotomy at another center. At 9 months of age, when he presented with increasing cyanosis, it was found that the central aortopulmonary shunt had become blocked and that there was narrowing of the left Blalock-Taussig shunt. A narrowed patent ductus was found supplying the right pulmonary artery. The patent ductus arteriosus (PDA) was stented, with the stent extending into the right pulmonary artery. When he presented to us at 1 year and 5 months of age, he had a patent but narrowed left Blalock-Taussig shunt, a blocked aortoright pulmonary shunt and a stented PDA supplying the right pulmonary artery, which had narrowed. He had an oxygen saturation of 72% on room air. There was severe stenosis of the pulmonary artery bifurcation at the site of PDA insertion (Figure 1). He had a right aortic arch. A computed tomographic angiogram revealed that he had a retroaortic innominate vein. A bidirectional Glenn procedure with pulmonary artery reconstruction was planned. After induction, a venous cannula in the left jugular vein was placed to detect any compression of the retroaortic innominate vein. The right and left jugular venous catheters showed equal pressures of 10 mm Hg. A redo median sternotomy was performed, and the aorta and right atrium were cannulated. All the systemic pulmonary shunts were controlled, and the patient was cooled to 18°C. The retroaortic innominate vein was dissected. It was found coursing just above the left pulmonary artery behind the PDA and inserting into the superior vena cava just above its junction with right atrium. The aorta was transected to provide unimpeded visualization of the pulmonary artery bifurcation. The pulmonary artery was opened, and the previous stent was removed piecemeal. The pulmonary artery was opened across the stenosed portion into the right and left pulmonary artery. The retroaortic innominate vein was opened parallel to the pulmonary artery from its insertion into the superior vena cava and anastamosed side to side, with the pulmonary artery providing a wide, unimpeded venous drainage into the pulmonary arteries and at the same time augmenting the stenosed portion of the pulmonary artery bifurcation (Figure 2). The aorta was reanastomosed, and the patient was weaned off cardiopulmonary bypass. The oxygen saturation was 87% with a fraction of inspired oxygen of 60%, and the left and