Repair of Shunts

Previously constructed systemic-to-pulmonary artery shunts must be closed at the time of total corrective surgery.

9-5-1. Classic Right Blalock-Taussig Shunt

Figure 9-51. The subclavian artery trunk of the right Blalock-Taussig shunt is usually easy to identify medial to the superior vena cava while working within the pericardial space.

Right Subclavian Cannulation

superior vena cava right subclavian artery trunk area of anastomosis ascending aorta right pulmonary artery

Figure 9-51. The subclavian artery trunk of the right Blalock-Taussig shunt is usually easy to identify medial to the superior vena cava while working within the pericardial space.

superior vena cava right subclavian artery trunk area of anastomosis ascending aorta right pulmonary artery ceph caud

Right Subclavian Cannulation

right subclavian artery trunk

Figure 9-52. Before cardiopulmonary bypass, a large silk suture is passed around the subclavian trunk and will be used to ligate the shunt.

right subclavian artery trunk

Figure 9-52. Before cardiopulmonary bypass, a large silk suture is passed around the subclavian trunk and will be used to ligate the shunt.

9-5-2. Classic Left Blalock-Taussig Shunt

Innominate Vein

innominate artery left subclavian artery trunk innominate vein ascending aorta

Figure 9-53. The proximal left subclavian artery trunk is isolated at its origin from the left-sided innominate artery. The dissection is performed high in the mediastinum above the innominate vein. Dissection here is safer because one avoids scar tissue, which may develop at the site of the subclavian artery to pulmonary artery anastomosis. An alternative exposure of this shunt is by dissection of the left pulmonary artery, starting within the pericardial space, until the region of the shunt anastomosis is seen.

innominate artery left subclavian artery trunk innominate vein ascending aorta

Figure 9-53. The proximal left subclavian artery trunk is isolated at its origin from the left-sided innominate artery. The dissection is performed high in the mediastinum above the innominate vein. Dissection here is safer because one avoids scar tissue, which may develop at the site of the subclavian artery to pulmonary artery anastomosis. An alternative exposure of this shunt is by dissection of the left pulmonary artery, starting within the pericardial space, until the region of the shunt anastomosis is seen.

9-5-3. Modified Blalock-Taussig Shunt

Modified Neck Dissection Scar
Figure 9-54. Dissection of this shunt is similar to the classic Blalock-Taussig shunt. The tubular Gore-Tex® graft is a firm structure and is palpable before full exposure. The Gore-Tex® graft is encased in a sheath of fibrous tissue which, when entered, can be easily dissected from the graft.
Gore Graft
Gore-Tex graft divided

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Figure 9-55. To close the shunt, the graft is divided to avoid neck artery distortion by a fixed and undivided graft with later patient growth. Stitch closure of the upper end of the graft is complete and the lower end will be closed.

Figure 9-55. To close the shunt, the graft is divided to avoid neck artery distortion by a fixed and undivided graft with later patient growth. Stitch closure of the upper end of the graft is complete and the lower end will be closed.

9-5-4. Waterston Shunt (Ascending Aorta to Right Pulmonary Artery)

Aorta Pulmonar Shunt

ascending aorta aorta to right pulmonary artery connection ascending aorta aorta to right pulmonary artery connection ceph

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Figure 9-56. For closure of this shunt, the distal ascending aorta or proximal arch is can-nulated to allow ample room for ascending aortic cross-clamping above the shunt anastomosis. Immediately after cardiopulmonary bypass is established, the shunt is compressed to avoid flooding of the lungs during initial bypass cooling before aortic clamping. Digital compression of the shunt is also required after cross-clamping and during delivery of cardioplegia solution. The proximal ascending aorta is opened anteriorly to expose the anastomosis.

Figure 9-56. For closure of this shunt, the distal ascending aorta or proximal arch is can-nulated to allow ample room for ascending aortic cross-clamping above the shunt anastomosis. Immediately after cardiopulmonary bypass is established, the shunt is compressed to avoid flooding of the lungs during initial bypass cooling before aortic clamping. Digital compression of the shunt is also required after cross-clamping and during delivery of cardioplegia solution. The proximal ascending aorta is opened anteriorly to expose the anastomosis.

Proximal Anastomosis Dilator
Figure 9-57. Multiple interrupted sutures are placed in the rim of the anastomosis to close it from side to side. This helps to avoid iatrogenic narrowing of the right pulmonary artery at this site.

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Proximal Anastomosis Dilator

Figure 9-58. Stitches are tied to complete the shunt closure. At this stage a small incision is made in the main pulmonary artery. The right pulmonary artery is measured with Hegar dilators or sizers to ensure that there is no narrowing at the site of shunt closure.

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Figure 9-58. Stitches are tied to complete the shunt closure. At this stage a small incision is made in the main pulmonary artery. The right pulmonary artery is measured with Hegar dilators or sizers to ensure that there is no narrowing at the site of shunt closure.

Waterston Shunt

ascending aorta right pulmonary artery

Figure 9-59. An alternative method of Waterston shunt closure is used when there is narrowing of the right pulmonary artery at the site of the anastomosis. The right pulmonary artery is detached from the ascending aorta, taking with it a small rim of aortic wall surrounding the anastomosis.

ascending aorta right pulmonary artery

Figure 9-59. An alternative method of Waterston shunt closure is used when there is narrowing of the right pulmonary artery at the site of the anastomosis. The right pulmonary artery is detached from the ascending aorta, taking with it a small rim of aortic wall surrounding the anastomosis.

ceph caud caud

Pulmonary Artery Picture

ascending aorta aortotomy closure right pulmonary artery

Figure 9-60. The aortotomy is closed primarily with a continuous suture. For hemostasis, a clamp is placed over the pulmonary arteriotomy.

ascending aorta aortotomy closure right pulmonary artery

Figure 9-60. The aortotomy is closed primarily with a continuous suture. For hemostasis, a clamp is placed over the pulmonary arteriotomy.

Arteriotomy Shunt

ascending aorta right pulmonary artery

Figure 9-61. The right pulmonary artery is inspected and then opened longitudinally over any area of stenosis proximal and distal to the arteriotomy.

ascending aorta right pulmonary artery

Figure 9-61. The right pulmonary artery is inspected and then opened longitudinally over any area of stenosis proximal and distal to the arteriotomy.

Coronary Arteriotomy

orifice of aorta to main pulmonary artery shunt left pulmonary artery orifice ascending aorta

Figure 9-63. Aortic cannulation and cross-clamping are high, and this allows adequate exposure of the ascending aorta to the main pulmonary artery shunt. This anastomosis is exposed by working through the main pulmonary artery.

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Figure 9-62. The right pulmonary artery is reconstructed with an anterior pericardial patch.

pericardial patch

9-5-5. Central Shunt (Ascending Aorta to Main Pulmonary Artery)

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Figure 9-62. The right pulmonary artery is reconstructed with an anterior pericardial patch.

orifice of aorta to main pulmonary artery shunt left pulmonary artery orifice ascending aorta

Figure 9-63. Aortic cannulation and cross-clamping are high, and this allows adequate exposure of the ascending aorta to the main pulmonary artery shunt. This anastomosis is exposed by working through the main pulmonary artery.

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Picture Left Pulmonary Arter

left pulmonary artery orifice right pulmonary artery orifice

Figure 9-64. The shunt is closed with multiple interrupted sutures.

left pulmonary artery orifice right pulmonary artery orifice caud

Figure 9-64. The shunt is closed with multiple interrupted sutures.

Goretex Shunt

ascending aorta main pulmonary artery left pulmonary artery shunt orifice

Figure 9-65. This anastomosis is repaired by working through an anterior opening in the proximal left pulmonary artery. Hypothermic circulatory arrest with low-flow cerebral perfusion is necessary during closure of the anastomosis.

9-5-6. Potts Shunt (Descending Aorta to Left Pulmonary Artery)

ascending aorta main pulmonary artery left pulmonary artery shunt orifice

Figure 9-65. This anastomosis is repaired by working through an anterior opening in the proximal left pulmonary artery. Hypothermic circulatory arrest with low-flow cerebral perfusion is necessary during closure of the anastomosis.

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Responses

  • aryan
    How is a pulmanary shunt repaired?
    7 years ago
  • Daniel
    How to fix lung shunt?
    6 years ago
  • aida
    Can a pulmonary shunt be fixed?
    4 months ago
  • mebrahtu abraham
    What can fix a pulmonary shunts?
    11 days ago

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