Off-pump hepatic to azygos connection via thoracotomy for relief of fistulas after a Kawashima procedure: Ten-year results

Abstract

The surgical connection can be performed safely with an off-pump technique that avoids the risks related to extracorporeal circulation and circulatory arrest. The results at 10 years follow-up confirmed the efficacy and safety of the surgical technique described.

Hepatic to azygos connection by autologous pericardial roll for Fontan completion

“…It significantly reduced the complications associated with re-sternotomy and cardiopulmonary bypass compared with the traditional extracardiac conduit technique. McElhinney et al 3 argued that a direct hepatic-to-azygos connection might provide more reliable mixing and a bilateral distribution of hepatic venous blood, while avoiding the formation of unilateral pulmonary arteriovenous malformations. A 10-year follow-up study confirmed the approach's efficacy and safety.…”

“…If the hepatic-to-azygos connection was performed simultaneously with the Kawashima procedure, it would be analogous to performing a one-stage Fontan completion. 7 To the contrary, to prolong the uncomplicated stage as long as possible, Arrigoni et al 3 suggested making the hepatic-to-azygos connection after initial signs of development of pulmonary arteriovenous malformations. However, there have been cases reporting that not all pulmonary arteriovenous malformations can be reversed.…”

Hepatic Vein Incorporation Into the Azygos System in Heterotaxy and Interrupted Inferior Vena Cava

“…16 The HV-azygos vein technique has subsequently been described by others. 20,[27][28][29] A proposed advantage of this technique is that it can be performed without the use of cardiopulmonary bypass through a lateral thoracotomy, therefore avoiding extensive mediastinal dissection. However, exposure to the azygos vein in this approach can be difficult because it is often behind or adjacent to the aorta.…”

“…Moreover, reoperation for bleeding when using a thoracotomy approach is not rare in this patient population owing to the extensive aortopulmonary collaterals in cyanotic Fontan candidates. 20 Because the ideal pathway configuration remains elusive, multiple other iterations for HVI have been reported, including bifurcated grafts that can be anastomosed to both PAs, T-junction grafts, and the use of differential offsets of a single HVI conduit to the undersurface of a unilateral PA. 23,24,30 Yang and colleagues reported the results of virtual implantation of computational fluid dynamics-optimized Y-shaped baffle in five patient-specific superior cavopulmonary connection models. 24 Although the Y-graft improved HF distribution relative to prior T-junction or offset designs among four of the five patients, important variability in performance was observed, and no follow-up data were provided given the simulated study design.…”

“…[16][17] More recently described are T-grafts, Y-grafts, and direct connection of the HVs into the azygos system. 11,[13][14][18][19][20] These techniques can be technically challenging, however, requiring dissection of fragile PAs in a reoperative situation or necessitating an operative field in the thoracic and potentially abdominal cavities.…”