Palliative cardiac surgery

Aorto Pulmonary Shunts

Dr. Rheecha Joshi
FCPS resident
Content
• Blalock–Taussig Shunt
• Waterston/ Cooley shunt
• Pott’s shunt
• Central /Mee’s shunt
• Sano’s shunt
Aortopulmonary shunts

• increases pulmonary blood flow in a cyanotic child with inadequate

pulmonary blood flow

• technical simplicity, good functionality, good long-term patency, easy

takedown , no residual shunt after closure
Classic Blalock–Taussig Shunt

• performed in 1944 by Alfred Blalock of the Johns Hopkins University

Medical Center

• Classic Blalock–Taussig shunt : direct end-to-side anastomosis of the

transected subclavian artery to the pulmonary artery

• through a thoracotomy approach on the side opposite the aortic arch

• The branches of the right subclavian artery are ligated and divided along with the
distal subclavian artery

• the subclavian artery is pulled through the loop formed by the right recurrent
laryngeal nerve

• The azygos vein is doubly ligated and divided

• 1 mg/kg of heparin is given intravenously

• The anastomosis is constructed to the main pulmonary artery with vascular clamps
Advantages
• does not require prosthetic material

• provides a precise amount of pulmonary blood flow limited by the

orifice of the subclavian artery

• the shunt grows with the patient, providing more pulmonary blood
flow as the child grows
Complications
• avoid performing the anastomosis to the right upper lobe branch

• sacrifices the subclavian artery/ hand or arm ischemia

• The affected arm is usually shorter/cooler to touch than the

contralateral arm and will not have a palpable pulse

• the subclavian artery may be so short as to cause the pulmonary

artery to be “pulled” up and kink
Takedown of the classic B–T shunt
• at the time of complete correction

• through a median sternotomy

• involves dissection posterior to the superior vena cava

• The artery can then be encircled and double ligation performed

Modified Blalock–Taussig Shunt

• The use of a PTFE tube for an aortopulmonary shunt was first

reported by Gazzaniga in 1976

• prosthesis of Dacron or PTFE interposed between the subclavian and

pulmonary arteries

• Most common indications : Right-sided obstructive lesions (tetralogy

of Fallot, pulmonary atresia, tricuspid atresia)
Advantages of Modified BT shunt
• preservation of the circulation to the affected arm

• Regulation of the shunt flow by the size of the systemic (subclavian or

innominate) artery;

• high early patency rate with PTFE prosthesis (Gore-Tex)

• guarantee of adequate shunt length

• ease of shunt takedown

Disadvantage
• leaking of serous fluid through the interstices of the fabric of the
PTFE

• result in excessive and prolonged chest tube drainage

• localized seroma formation around the graft

• occurs in 3–5% of patients.

• a right or left thoracotomy or a median sternotomy (depends on the subclavian
and pulmonary artery anatomy, the presence and location of a ductus arteriosus,
the great vessel relationship ,surgeon preferences

• The sternotomy approach is technically ease, fewer shunt failures and if

necessary, the shunt can be performed with the use of cardiopulmonary bypass

• Access patent ductus arteriosus for ligation to remove a source of competitive

flow
• size of the PTFE graft selected is based on the size of the patient

• the heparin-bonded "stretch“ PTFE

• 3.0-mm shunt for neonates <2.0 kg

• 3.5-mm shunt for neonates 2.0 - 4.0 kg
• 4.0-mm shunt for infants >4 kg, rarely a 5-mm shunt in an infant over 5 kg

• complete repair at 6–9 months of age

• The PTFE is cut to size before the clamps are placed

• the clamps distort the relative distance between the subclavian and pulmonary arteries

• The PTFE graft is beveled and an arteriotomy is created in the inferior aspect of the
subclavian artery after placement of a vascular clamp

• The PTFE graft is anastomosed to the opening in the subclavian artery

• The clamp on the subclavian artery is left in place until the pulmonary artery
anastomosis is completed
• Repositioning the clamp to the PTFE graft may increase the risk of
blood stasis and shunt thrombosis

• The pulmonary artery is controlled with another vascular clamp

• A longitudinal arteriotomy is created in the superior aspect of the

right pulmonary artery

• PTFE graft is anastomosed to the pulmonary artery

• there should be a nearly instantaneous rise of approximately 15–20% in the patient’s
oxygen saturation as monitored by pulse oximetry

• A thrill palpable in the shunt and in the distal pulmonary artery

• maintain adequate systemic perfusion pressure prevent early shunt thrombosis
• The heparin is not routinely reversed with protamine unless there is excessive bleeding
from the suture lines

• The graft : groove posterior to the superior vena cava

• an aspirin suppository (10 mg/kg) in the operating room when the shunt is completed
and then 10 mg/kg PO daily until shunt takedown
Takedown of a modified BT shunt
• shunt is identified by dissecting the medial aspect of the superior vena cava
posteriorly

• Locating a shunt on the left side ?? identified either by dissecting along the left
pulmonary artery, along the aorta to the shunt, or by entering the pleural space and
approaching the shunt laterally

• thick fibrous “peel,” around the PTFE graft. Enter the plane between the “peel” and
the PTFE graft Enough graft length for double hemoclip application and the graft is
divided between the hemoclips

• the distal graft can be left in place and typically does not cause a residual peripheral
pulmonary artery stenosis
Waterston/Cooley Shunt
• Anastomosis between posterior aspect of ascending aorta and
anterior right pulmonary artery

• 1962 by David Waterson by right thoracotomy approach, anastomosis

---> posterior to SVC

• Denton Cooley performed the anastomosis in intracardiac fashion

anterior to SVC
Waterston shunt
• in infants aged less than 2 weeks

• Preservation of subclavian artery

• No prosthetic material

• Significant distortion of RPA as the patient grows aorta rotates , the

anastomosis applies traction to RPA and kinks and distorts RPA
• Possibilities of excessive or inadequate pulmonary blood flow

• Not a controlled shunt… if incision in aorta and PA are too long,large

anastomosis and excessive pulmonary flow and causes pulmonary
vascular disease

• If short incision and short anastomosis…. Patient remains cyanotic

Take down of Waterston shunt
• Dissect the PA before CPB
• Aorta cross clamped distal to shunt

• Occlude the PA to prevent cardioplegia solution runoff

• Incision is made along the original anastomosis site

• Opening in aorta closed primarily with running sutures and for RPA .. Pericardial or PTFE
Patch closure

• Another approach : to open the aorta anteriorly after the cross clamp and Close the
opening from within the aorta itself
POTTS SHUNT/ Potts-Smith-Gibon shunt
• Anastomosis between descending thoracic aorta and posterior LPA via
left thoracotomy approach

• 1946 by Willis J Potts in Chicago

• Partially occluding Descending thoracic aorta to minimize the risk of

paraplegia

• parallel 4-mm incisions made in the descending thoracic aorta and the
posterior left pulmonary artery
Complication
• Aneurysm of LPA

• Large anastomosis : Congestive heart failure

• inadequate incision: cyanotic child

• Potts shunt could not be used with right arch because right bronchus
lies between pulmonary artery and the aorta

• Difficulty in Taking down

Take Down Of Potts Shunt
• Simple ligation of shunt … uncontrolled hemorrhage. Risk of air embolism and
stroke if brachiocephalic vessels are not controlled

• Preferred technique is DHCA . CPB established..aortopulmonary anastomosis is

digitally occluded with finger from outside the PA to limit the left to right shunt
and improve the efficiency of cooling

• The brachiocephalic vessels are snared. Under DHCA , LPA is opened and the
communication between LPA and aorta is closed with PTFE patch.
• All air is evacuated from ascending aorta before snares are released to the
brachiocephaic vessels
Central shunt/ Mee’s shunt

• anastomosis between the ascending aorta and the main pulmonary

artery with prosthetic materials

• prevention of distortion of pulmonary arteries, provision of equal

pulmonary blood flow to both lungs, lower occlusion rate, avoidance
of subclavian artery steal and ease of closure

• It can be performed only in infants with a patent ductus arteriosus or

some other source of pulmonary blood flow
Mee shunt : an end-to-side anastomosis between a transected main pulmonary artery and
the side of the ascending aorta
Sano's shunt

• right ventricle to pulmonary artery shunt in low birth weight infants.

• 4-mm PTFE tube in infants wt< 2.5 kg ,5-mm PTFE tube in infants wt>2.5 kg

• A 5- or 6-mm Gore-Tex graft is placed from the right ventricle to the pulmonary artery
bifurcation

• allows for placement of a larger diameter shunt which may decrease the risk of shunt
thrombosis, preservation of diastolic coronary perfusion pressure .This shunt may be
clipped and subsequently dilated in the cardiac catheterization lab if required

• requires cardiopulmonary bypass, aortic cross clamping for the proximal shunt
anastomosis in order to prevent air emboli, and a right ventriculotomy incision
Wanna-be” Blalock-Taussig's shunt

• Ductus stenting in neonates and infants with duct-dependent cyanotic

congenital heart disease

• The procedure carries no risk of serious complications or pulmonary artery

distortion and stenosis and gains time for the child and the pulmonary arteries
to grow

• leaves the operative field for definitive surgery untouched

• Ruiz and Bailey named ductus arteriosus stenting a “wanna-be” Blalock-

Taussig's shunt
THANK YOU …..
REFERENCES
• Pediatric Cardiac surgery ( Constantine Mavroudis/Carl Backer)

• Atlas of Pediatric cardiac surgery

• Mastery of cardiothoracic surgery