Coronary-to-pulmonary artery collaterals in pulmonary atresia

Abstract

A 2-month-old baby with ventricular septal defect and pulmonary atresia was found to have coronary-to-pulmonary artery collaterals. Cardiac computed tomography confirmed the coronary collaterals and showed the absence of other systemic to pulmonary artery collaterals. Although these collaterals do not cause coronary ischemia, it is important to delineate them by accurate imaging to plan the appropriate surgical strategy.

Major Aortopulmonary Collateral Arteries

“…By the 40th day of gestation, the lung receives blood supply from these segmental arteries, as well as from the sixth branchial arch-derived branches (future pulmonary arteries), which are in continuity to the outflow of the right ventricle. By the 50th day of gestation, as the segmental arteries regress, some bronchopulmonary segments or lobules remain connected to the right ventricle and others to the aorta via the segmental arteries (Fig 2) (13). As the lungs develop, they are exclusively supplied by the central pulmonary arteries (mediastinal main pulmonary artery, right pulmonary artery, and left pulmonary artery) derived from the sixth branchial arches.…”

“…As the lungs develop, they are exclusively supplied by the central pulmonary arteries (mediastinal main pulmonary artery, right pulmonary artery, and left pulmonary artery) derived from the sixth branchial arches. However, if the pulmonary arteries are not well developed, the ductus arteriosus and segmental arteries from the aorta persist to compensate the pulmonary blood flow, as depicted in Figure 3 (12,13). There are variations in the number, origin, course, branching patterns, and anastomoses of MAPCAs with other pulmonary arteries (such as in Fig 4 with central, lobar, and segmental pulmonary arteries), which may have stenosis at multiple locations for variable lengths (4).…”

“…On the basis of the vessel of origin, MAPCAs are classified as type I, II, or III (Fig 5). MAPCAs may arise from the celiac artery and rarely from the coronary arteries, as shown in Figure 6 (2,4,8,12,13,15).…”

“…For an excellent postoperative outcome, the maximum number of lung segments must be perfused by the native pulmonary arterial branches (13). Hence, it is crucial to describe the detailed anatomy of blood vessels supplying the lung segments as independently or jointly supplied by native pulmonary branches or MAPCAs, as shown in Figure 3.…”

“…Unifocalization can be performed by direct anastomosis or by the placement of interposition grafts (27). Definitive intracardiac repair has favorable results if 15 of the 20 bronchopulmonary segments are connected to the pulmonary circulation from the right ventricle (13). A Nakata index of less than 150 mm 2 /m 2 or Qp/Qs of less than 1 at CT or MRI indicates the need for unifocalization or staging the definitive surgery (11,21).…”