title: Systemic venous collateral channels causing desaturation after bidirectional cavopulmonary anastomosis: evaluation and management.
abstract: OBJECTIVE
  We sought to characterize the frequency, anatomic details and factors associated with the development of collateral channels between the superior and inferior vena caval systems after bidirectional cavopulmonary anastomosis.
  
  
  BACKGROUND
  It is well known that systemic venous collateral channels often develop in patients who have undergone a classic Glenn shunt or bidirectional cavopulmonary anastomosis and that such collateral channels can lead to profound systemic desaturation. However, there have been few reports focusing on this problem.
  
  
  METHODS
  Fifty-four patients (median age 1.4 years) who underwent bidirectional cavopulmonary anastomosis and had preoperative and postoperative angiograms available for review were studied retrospectively. Postoperative connections between the superior and inferior vena caval systems were identified and measured. Sites of collateral origin and entry from the superior and inferior venous systems, as well as the course taken in between, were recorded.
  
  
  RESULTS
  At follow-up angiography performed 17 days to 46 months postoperatively, a total of 31 venous collateral channels were observed in 18 patients with a wide variety of primary morphologic diagnoses. The majority of these collateral channels (80%) originated from the brachiocephalic vein or its junction with the superior vena cava, and over half of them drained below the diaphragm. In patients who developed venous collateral channels, the mean transpulmonary pressure gradient early after bidirectional cavopulmonary anastomosis was higher (p = 0.005), and mean arterial oxygen saturation at follow-up was lower (p = 0.009). There were trends toward higher superior vena caval pressure early after the operation and at follow-up in patients with collateral channels and a higher likelihood of absent upper lobe pulmonary blood flow in these patients. Successful coll embolization of 10 collateral channels was performed in six patients, with a median increase in arterial oxygen saturation of 16%.
  
  
  CONCLUSIONS
  Angiographically detectable systemic venous collateral channels develop after bidirectional cavopulmonary anastomosis in a substantial number of patients (33% in the present series) with a variety of forms of a functional univentricular heart. Patients with venous collateral channels can be treated successfully with coil embolization, but the indications for embolization will depend on individual circumstances.
authors.affiliation: Division of Cardiothoracic Surgery, University of California, San Francisco, USA.
authors.forename: D B
authors.initials: DB
authors.lastname: McElhinney
authors.forename: V M
authors.initials: VM
authors.lastname: Reddy
authors.forename: F L
authors.initials: FL
authors.lastname: Hanley
authors.forename: P
authors.initials: P
authors.lastname: Moore
mesh_terms: D000293:Adolescent; D000328:Adult; D016121:Brachiocephalic Veins / Q000000981:diagnostic imaging; D002648:Child; D002675:Child, Preschool; D003097:Collateral Circulation / Q000502:physiology*; D017023:Coronary Angiography; D005500:Follow-Up Studies; D018610:Heart Bypass, Right; D006330:Heart Defects, Congenital / Q000503:physiopathology / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D007223:Infant; D010100:Oxygen / Q000097:blood; D012189:Retrospective Studies; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging / Q000503:physiopathology; D014683:Vena Cava, Superior / Q000000981:diagnostic imaging / Q000503:physiopathology
chemical_list: D010100:Oxygen