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correspondence

Indian Pediatr 2010;47: 198-199

Pseudoaneurysm Following Modified Blalock Taussig Shunt


Syed Ahmed Zaki and  Preeti Shanbag,

Department of Pediatrics, Lokmanya Tilak Municipal General Hospital,  Sion, Mumbai, India.

Email: [email protected]
 


The modified Blalock-Taussig (BT) shunt is a common palliative procedure for congenital cyanotic heart disease (CHD) with diminished pulmonary blood flow(1). In developing countries, definitive surgery usually gets delayed due to limited resources and expertise(2). Children with cyanotic CHD and BT shunt often present to the pediatrician resulting in some of the complications of BT shunt being misdiagnosed(3,4).

A 1-year-old boy was admitted with cough and fever for 7 days, and breathlessness for 1 day. He was diagnosed to have tetralogy of Fallot at 3 months of age. Echocardiography revealed a normal visceroatrial arrangement (situs solitus) and non-restrictive ventricular septal defect with an overriding aorta. There was infundibular and valvar pulmonary stenosis and a right-sided aortic arch. At 11 months of age a left-sided modified BT shunt was done for frequent cyanotic spells. The present symptoms developed a month after surgery.

On admission, the child was afebrile with heart rate 180/minute, respiratory rate 60/minute with intercostal retractions and blood pressure 94/52 mm Hg. There was a grade 3/6 ejection systolic murmur in the 2nd left intercostal space. Bronchial breathing was heard in the left infraclavicular and axillary areas. The liver was palpable 4 cm and the spleen 2 cm below the costal margin. Hemoglobin was 12 g/dL and total leukocyte count was 13,500/cu.mm (polymorphs 85%, lymphocytes15%). Chest X-ray showed an opacity in the left upper zone. Intravenous cefotaxime and amikacin were started for a presumptive diagnosis of pneumonia. Anti-failure management with digoxin and furosemide was initiated. However there was no improvement even after 7 days. A repeat chest X-ray showed persistence of the opacity in the left upper lobe, hence shunt- related pathology was suspected. High-resolution computed tomography scan of the chest showed regression of the distal end of the BT shunt from the left pulmonary artery with a large hematoma in the left upper lobe causing atelectesis of the underlying lung parenchyma with a shifting of mediastinum to the right. There was aneurysmal dilatation of the left subclavian artery with a large crescentric thrombus (Fig.1). The child was taken up for surgical resection of the pseudoaneurysm. Intraoperatively, the shunt was found to be completely occluded and the distal end of the graft had partially dehisced from the anastomotic site. There was aneurysmal dilatation of the left subclavian artery with a large crescentric thrombus. However the patient did not survive the procedure.

Fig.1 High-resolution computerized tomography scans of chest showing from above below: Pseudoaneurysm of the BT shunt (first arrow) with hematoma around the shunt (second arrow) causing atelactasis of the underlying lung (third arrow).

Common complications of BT shunt include shunt stenosis and occlusion, nerve damage at the time of operation, excessive pulmonary blood flow, serous fluid leak and false aneurysm(3). A pseudoaneurysm after a modified BT shunt may cause rupture or compression of mediastinal structures, collapse of underlying lung parenchyma, and shunt occlusion and bacteraemia. The appearance of a localized mass on the chest film surrounding the BT shunt requires the exclusion of hematoma, aneurysm, or inflammation(5). Such patients may be misdiagnosed and treated as pneumonia.

Through this case we wish to highlight that shunt-related pathology should be kept in mind when dealing with children with a BT shunt.

Acknowledgment

Dr Sandhya Kamath, Dean and Dr Anupama Mauskar for permitting to publish and patient management, respectively.

References

1. Laks H, Marco JD, Willman VL. The Blalock-Taussig shunt in the first six months of life. J Thorac Cardiovas Surg 1975; 70: 687-691.

2. Rana JS, Ahmad KA, Shamim AS, Hassan SB, Ahmed MA. Blalock-Taussig Shunt: Experience from the Developing World. Heart Lung Circ 2002; 11: 152-156.

3. Pongprot Y, Silvilairat S, Woragidpoonpol S, Sittiwangkul R, Phornphutkul C. Pseudoaneurysm following modified Blalock-Taussig shunt: a rare complication mimicking pulmonary disease. J Med Assoc Thai 2003; 86:365-368.

4. Coren ME, Green C, Yates R, Bush A. Complications of modified Blalock- Taussig shunts mimicking pulmonary disease. Arch Dis Child 1998; 79: 361- 362.

5. Tabaee SA, Rostami A, Givtaj N, Mali S, Pourabasi SM, Arefi S. Modified Blalock-Taussig Shunt and Giant Perigraft Reaction. J Teh Univ Heart Ctr 2007; 3: 173-176.
 

 

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