Images and Case Reports in Interventional Cardiology Paravertebral Venous Access for Closure of a Collateral in a Pediatric Patient After Fontan Operation

We report on a 16-year-old female patient with tricuspidatresia, ventricular and atrial septal defect, hypoplastic right ventricle, and pulmonary stenosis. A modified Blalock-Taussig shunt was placed within the first month of life, followed by a modified bilateral bidirectional Glenn anastomosis at 3 years and a total cavopulmonary anastomosis (TCPC) at 5 years of age. The azygous vein was ligated at the time of the Glenn procedure. The patient presented with new cyanosis (arterial oxygen saturations were 86 % at rest and 76 % at exercise) and a decrease in exercise capacity 11 years after TCPC. By cardiac catheterization, a significant right-to-left shunt across a collateral vessel could be detected, originating from the vertebral venous plexus and draining via the azygous system with a single opening to the pulmonary vein (Figure 1A and 1B). Repeated attempts were made at transcatheter closure through the small and tortuous feeding vessels connected to the jugular veins but were unsuccessful. Therefore, a combined surgical and trans-catheter approach (hybrid procedure) was performed: After a median sternotomy, the left atrium was punctured and a long sheath was inserted into the pulmonary vein, which drained the collateral vessel. Because of the large diameter of the collateral, its distant orifice, and its tortuosity, however, it was not possible to advance an introducer sheath or a closure device into the collateral vessel. Therefore, a multidisciplinary interventional approach was applied. With the patient in prone position and under deep conscious sedation, a CT scan was performed (Siemens Somatom Definition AS, application of 80 mL Accu-paque 350; flow, 2.5 mL/s; delay, 50 seconds; slice thickness, 5 mm, Erlangen, Germany) and identified a 4-mm paravertebral vein at the level of the 4th to 5th thoracic vertebra as a small feeding vessel. Under real-time CT guidance, this vessel was punctured using a 4F Micropuncture introducer set (Coo