Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot

Abstract

Background Due in part to the heterogeneity of the pulmonary circulation in patients with tetralogy of Fallot and major aortopulmonary collateral arteries (MAPCAs), research on this condition has focused on relatively basic anatomic characteristics. We aimed to detail pulmonary artery (PA) and MAPCA anatomy in a large group of infants, assess relationships between anatomy and early surgical outcomes, and consider systems for classifying MAPCAs. Methods and Results All infants ( <1 year of age) undergoing first cardiac surgery for tetralogy of Fallot/MAPCAs from 2001 to 2019 at Stanford University were identified. Preoperative angiograms delineating supply to all 18 pulmonary segments were reviewed for details of each MAPCA and the arborization and size of central PAs. We studied 276 patients with 1068 MAPCAs and the following PA patterns: 152 (55%) incompletely arborizing PAs, 48 (17%) normally arborizing PAs, 45 (16%) absent PAs, and 31 (11%) unilateral MAPCAs. There was extensive anatomic variability, but no difference in early outcomes according to PA arborization or the predominance of PAs or MAPCAs. Patients with low total MAPCA and/or PA cross‐sectional area were less likely to undergo complete repair. Conclusions MAPCA anatomy is highly variable and essentially unique for each patient. Though each pulmonary segment can be supplied by a MAPCA, central PA, or both, all anatomic combinations are similarly conducive to a good repair. Total cross‐sectional area of central PA and MAPCA material is an important driver of outcome. We elucidate a number of novel associations between anatomic features, but the extreme variability of the pulmonary circulation makes a granular tetralogy of Fallot/MAPCA classification system unrealistic.

Comprehensive diagnostic catheterization in children with major aortopulmonary collateral arteries: A review of catheterization technique and anatomic nomenclature

“…Whereas some are clearly large (and MAPCA redundant, “dual supply” ) and some are clearly very small ( “functionally single‐supply” ), in borderline cases there is some degree of subjectivity in how to define the connection. Generally, our surgical approach is to unifocalize or augment all questionable or borderline MAPCAs. Varying MAPCA origins, though associated with different supply types and PA arborization patterns, do not have an impact on our surgical management and do not seem to have a significant impact on outcomes 2 . The terms “direct” and “indirect”, which were historically used to distinguish between MAPCAs originating from the descending thoracic aorta and the head and neck vessels, are therefore no longer commonly utilized 4,7 …”

“…The pulmonary vasculature supplied by a PDA is normally a favorable feature in this complex condition, as long as it is not allowed to remodel adversely in response to prolonged high pressure and flow or absent antegrade flow resulting from closure. A unilateral PDA is found in about 10% of patients with TOF/MAPCAs 1–3 …”

“…On the other end of the spectrum, patients with absent intrapericardial PAs tend to have the majority of their MAPCAs from the descending thoracic aorta. The presence of a PDA or anomalous PA arising from the ascending aorta has an association with coronary artery MAPCAs to the contralateral PA 2 …”

“…Varying MAPCA origins, though associated with different supply types and PA arborization patterns, do not have an impact on our surgical management and do not seem to have a significant impact on outcomes. 2 The terms "direct" and "indirect", which were historically used to distinguish between MAPCAs originating from the descending thoracic aorta and the head and neck vessels, are therefore no longer commonly utilized. 4,7…”

“…1 In patients with MAPCAs, each lung segment can be supplied by MAPCAs, central PAs, or both, with varying degrees of stenoses and types of interconnections between lung segments. [2][3][4] Achieving an optimal surgical outcome first requires a thorough preoperative evaluation of the anatomy and physiology of a patient's pulmonary circulation.…”