Acute and late obstruction of a modified Blalock–Taussig shunt: a two-center experience in different catheter-based methods of treatment

Moszura, Tomasz; Zubrzycka, Maria; Michalak, Krzysztof W.; Rewers, Bożena; Dryżek, Paweł; Moll, J; Sysa, Andrzej

doi:10.1510/icvts.2009.219741

Cited by 35 publications

(50 citation statements)

References 10 publications

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“…In general, however, the total amount of rTPA required for a thrombolysis procedure will depend on the extent of the thrombus formation, response to the drug, coagulation status of the patient, and complications associated with the procedure. There are several case reports on the local administration of rTPA to treat thrombosis of modified Blalock-Taussig shunts [28,[35][36][37]. In these cases, resolution of the clotted grafts was achieved circulation would be limited.…”

Section: Discussionmentioning

confidence: 99%

Catheter-Directed Thrombolysis for Occluded Central (Ascending Aorta-to-Pulmonary Artery) Shunts: Importance of Shear Stress-Induced, Platelet-Mediated Thrombosis

Singh¹,

Sernich²,

Siwik³

et al. 2016

jshd

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A central (ascending aorta-to-pulmonary artery) shunt is a standard palliative operation for infants with cyanotic congenital heart disease. Thrombosis of these shunts can be life-threatening. We report our experience with catheter-directed thrombolysis using recombinant tissue plasminogen activator to locally treat totally occluded central shunts as an alternative to surgery. Ten patients (median age 47 days) successfully underwent the procedure. Following thrombolysis, shunt patency was verified by angiography. The arterial oxygen (O 2 ) saturations in 100% O 2 increased from a median value of 55% to 90%. Major bleeding did not occur in any patients. Computational fluid dynamics was used to identify a relationship between shunt hemodynamics and thrombosis. We retrospectively analyzed blood flow through simulations of these shunts as they would have appeared prior to obstruction. The calculations revealed that flow negotiating "angulated" portions of these central shunts produced wall shear stresses of 157-168 Pa (or N/m 2 ), with shear rates reaching 31,400-33,600/s. These values are easily high enough to initiate platelet activation/aggregation, leading to thrombus formation. We conclude that: 1) catheter-directed thrombolysis can be used to rapidly, effectively, and safely resolve total central shunt occlusion in critically ill neonates and 2) central shunts containing prominent angulation are at risk for developing shear stress-induced, plateletmediated thrombosis. This finding is clinically important as this flow-directed process is not affected by prophylactic aspirin against shunt thrombosis.

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Section: Discussionmentioning

confidence: 99%

Catheter-Directed Thrombolysis for Occluded Central (Ascending Aorta-to-Pulmonary Artery) Shunts: Importance of Shear Stress-Induced, Platelet-Mediated Thrombosis

Singh¹,

Sernich²,

Siwik³

et al. 2016

jshd

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“…Despite early anticoagulation and anti-aggregant therapy, the early or late shunt occlusion rate is still high [2]. The usual cause of shunt obstruction is a thrombus formation closing the narrow lumen of the graft, which in a majority of cases is additionally narrowed by coexisting distal stenosis present at the junction of the BT graft and the narrow pulmonary artery branch.…”

Section: Discussionmentioning

confidence: 99%

“…Most have been performed for stenosed classical BTS, where direct end-to-side anastomosis of the subclavian artery to the pulmonary artery has been performed [2].…”

Section: Discussionmentioning

confidence: 99%

Recanalisation of Totally Occluded Modified Blalock Taussig Shunt by Balloon Angioplasty 48 Hours after its Construction

Hanna¹,

Smaira²,

Fenianos³

et al. 2016

Intensive & Crit Care

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An 18 months old boy with TOF and deep cyanosis was admitted for a palliative surgery. The cardiac catheterization had shown a hypoplastic pulmonary tree and an abnormal LAD crossing the infundibulum. He was well vaccinated but no Palivizumab injection was performed.The laboratory tests showed minor thalassemia and iron deficiency. No hemostasis disorder was documented. A 4 mm Gore-Tex tube was inserted between the arterial brachiocephalic trunk (ABCT) and the proximal right pulmonary artery. Immediate heparin therapy (500 UI/Kg/day) was initiated as well as oral Aspirin (5 mg/Kg/day). An Adequate ACT level (64 seconds) was rapidly achieved and the shunt patency was documented by echocardiography and color Doppler 24 hours later. At 36 hours after surgery, the SpO 2 suddenly dropped from 83 to 60%. Continuous flow profile of the shunt could not be identified by Doppler echocardiography. At catheterization, a 5F femoral arterial short introducer was inserted. A selective angiogram in the ABCT, using a 5F mammary catheter (Cordis), confirmed complete shunt occlusion at 5mm of the aortic connection (Figure 1). Using a 0.014" "Cross It" guide wire (Abott), the shunt was crossed to place the wire (Figure 1-3) distally in the right pulmonary branch. A 4F Right Judkins cathter (Cordis special) was used to cross the shunt over the 0.014" wire and then, a 0.035" exchange wire was used to introduce a multipurpose 5F guiding catheter in the right pulmonary artery. After that, the 0.014" was replaced in the guiding catheter and using a 4 mm × 20 mm coronary TREK balloon (Abott) multiple hand inflations in the shunt were repeated to reestablish the shunt patency (Figure 2). At the final angiogram, aortic and pulmonary shunt's ends were free of narrowing or kinking (Figure 3). The SpO 2 increased to 85% and heparin therapy with oral Aspirin was continued and oral Clopidogrel (1 mg/Kg/d) was added. He was extubated the next day and fed normally. Repeated Doppler echocardiography showed the patency of the shunt. Three days later, high grade fever and cough appeared. The nasopharyngeal secretions tests showed the presence of RSV. The Chest X-ray showed bilateral infiltrates (Figure 4) and WBC count was 3500 (N36%; L69%), CRP 26 mg/dL. The dyspnea exacerbated and tracheal bleeding followed by anuria occurred. Although no bacterial super infection was documented, a large spectrum anti-biotherapy was started. High frequency ventilation was used but despite all therapeutic measures the hypoxia and hypercapnia worsened and the child died on the 8 th day after the surgery. Cardiac ultrasound Recanalisation of Totally Occluded Modified Blalock Taussig Shunt by Balloon Angioplasty 48 Hours after its Construction AbstractAn 18 months old boy with TOF benefited from a BTS. Deep cyanosis reappeared 48 hours later and continuous flow profile of the shunt could not be identified by Doppler echocardiography. At catheterization, angiogram confirmed complete shunt occlusion. The shunt was recanalized using a coronary guide wire and a 4mm diame...

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“…The largest series to date reports 23 occluded mBTSs of which 22 were able to be successfully reopened with one or more therapeutic modalities which included balloon angioplasty (22 cases), stent placement (3 cases), and recombinant tPA (12 cases). 75 A second case series involved 3 mBTTs that were reopened with transcatheter stent therapy. 76 The third transcatheter modality involves rheolytic therapy where the thrombus is entrained into the catheter via a high-velocity retrograde saline jet within the catheter lumen, resulting in the removal of the thrombus through the catheter lumen.…”

Section: Shunt Thrombosis: Prevention Detection and Managementmentioning

confidence: 99%

Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care

Giglia

DiNardo

Ghanayem

et al. 2012

World J Pediatr Congenit Heart Surg

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Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.

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Acute and late obstruction of a modified Blalock–Taussig shunt: a two-center experience in different catheter-based methods of treatment

Cited by 35 publications

References 10 publications

Catheter-Directed Thrombolysis for Occluded Central (Ascending Aorta-to-Pulmonary Artery) Shunts: Importance of Shear Stress-Induced, Platelet-Mediated Thrombosis

Catheter-Directed Thrombolysis for Occluded Central (Ascending Aorta-to-Pulmonary Artery) Shunts: Importance of Shear Stress-Induced, Platelet-Mediated Thrombosis

Recanalisation of Totally Occluded Modified Blalock Taussig Shunt by Balloon Angioplasty 48 Hours after its Construction

Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care

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