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Archives of cardiovascular diseases
Volume 110, n° 4
pages 223-233 (avril 2017)
Doi : 10.1016/j.acvd.2016.09.004
Received : 30 May 2016 ;  accepted : 15 September 2016
Cliinical research

Vascular anatomy in children with univentricular hearts regarding transcatheter bidirectional Glenn anastomosis
Anatomie vasculaire chez les enfants avec des cœurs univentriculaires concernant la dérivation cavopulmonaire partielle par voie percutanée
 

Figure 1




Figure 1 : 

Definition of the morphometric measurements for the convenient vascular arrangement. A, B, C and C*. Regular axial, oblique sagittal and oblique coronal planes transecting the superior vena cava (SVC) and the right pulmonary artery (RPA) from a representative patient, as described in the text. D, E, F and F*. Performed measurements by numbers: the diameters of the RPA (1) and the SVC (8); the shortest distance between the two vessels (3 & 5); the width of the tightest intervascular contact (2); the length of the proximal SVC cranial to the level of the RPA (9); and the distance between the RPA branching point (star in C* and F*) and the level of the SVC (10). Additionally, the angle between the anteroposterior plane and the line perpendicular to the RPA wall adjacent to the SVC (4), as well as two angles formed by the line passing the RPA centre and the SVC-RPA contact area's most cranial border and the longitudinal SVC axis (7) or the transverse plane (8), respectively, were measured. br.v: brachiocephalic vein; DAo: descending aorta; LA: left atrium; LPA: left pulmonary artery; mPA: main pulmonary artery; RA: right atrium; r.b: right bronchus.


Figure 2




Figure 2 : 

Definition of the morphometric measurements for the vascular arrangement with right pulmonary artery (RPA) early branching. A, B, C and C*. Oblique axial, oblique sagittal and oblique coronal planes transecting the superior vena cava (SVC) and the prebranching RPA in a representative patient, as described in the text. The star indicates the RPA branching point, defined as a crossing point of the longitudinal axes of the RPA branches. D, E, F and F*. Performed measurements by numbers: the shortest distance between the SVC and the RPA without interposition of its branches (3 & 5), and the width of the intervascular space free of adjacent structures (2). The remaining measurements are as described in Fig. 1. AAo: ascending aorta; br.v: brachiocephalic vein; DAo: descending aorta; LA: left atrium; LPA: left pulmonary artery; mPA: main pulmonary artery; RA: right atrium; r.b: right bronchus.


Figure 3




Figure 3 : 

Morphology of the region with adjacent right pulmonary artery (RPA) and superior vena cava (SVC) in three representative patients with vascular anatomy convenient for immediate SVC-to-RPA wire passage and stent deployment. A, C and E are the oblique ventral views and B, D and F are the left lateral views of the maximum-intensity projections, with the SVC being immediately anterior to RPA. Images in A and B are from a patient with the typical arrangement of the SVC posterior aspect partially “wrapping” the adjacent RPA. Dotted circles point to the orifice of brachiocephalic vein (br.v), while dashed lines represent the contours of the posteriorly-located RPA and its branches, which are clearly visible lateral to the SVC. Double arrows point to the range of different lengths of the proximal SVC (7–21mm) allowing deployment of the stent without covering the brachiocephalic vein orifice. AAo: ascending aorta; LA, left atrium; p.v., pulmonary vein; RA: right atrium.


Figure 4




Figure 4 : 

Morphology of the region with adjacent right pulmonary artery (RPA) and superior vena cava (SVC) in three representative patients with the RPA early branching pattern. A, C and E are oblique dorsal views and B, D and E are oblique cranial views of the maximum-intensity projections, with the SVC being in contact with RPA branches. Asterisks indicate the systemic-to-RPA shunt, while dashed lines represent the contours of the anteriorly-located SVC. The dotted lines refer to the trajectory of the perforation wire through the extravascular space between the SVC and the central RPA, to avoid entrance into its upper branch. Note that passage of the wire and, thus, SVC-to-RPA stent deployment, would be still possible even in the presence of the early RPA branching pattern. AAo: ascending aorta; DAo: descending aorta; LA: left atrium; LPA: left pulmonary artery; mPA: main pulmonary artery; p.v., pulmonary vein.


Figure 5




Figure 5 : 

Spatial relationship of the vascular walls in a patient with univentricular heart, transposition of the great arteries, pulmonary artery banding and the representative convenient vascular arrangement. A. Cranio-right lateral view of the whole reconstruction. B and C. Ventrocranial and dorsocaudal views of the oblique transverse cuts through the superior vena cava (SVC) and right pulmonary artery (RPA), respectively. The dashed circle schematically represents the cross-section of the presumably suitable ∼9mm stent, corresponding to the SVC diameter in this patient. Dotted arrows indicate the RPA branches being relatively close to the eventual stent. D and E. Left and right views of the sagittal cut through the SVC, respectively, to illustrate schematically the two methods of stent deployment to create an SVC-to-RPA connection: perpendicularly to the SVC blood flow, with a need to separately close off the SVC-right atrium (RA) junction (asterisk in D); and in a craniocaudal stent orientation through the cranial border of the SVC-RPA contact with the simultaneous RA-SVC junction occlusion (asterisk in E). Note, however, the short length of the proximal SVC, making it possible to avoid covering of brachiocephalic vein (br.v) orifice. F. Volume-rendered reconstruction of the vessels from the same patient, 7 months after surgical creation of the bidirectional Glenn anastomosis, which has a very similar SVC-RPA angulation (dashed line) to the eventual connection created by the craniocaudally oriented stent. LA: left atrium; LPA: left pulmonary artery; r.br: right bronchus; tr: trachea.


Figure 6




Figure 6 : 

A. Schematic representation of the posteroanterior C-arm position (12–68° of cranial angulation; α2), and the resulting angiographic projection for right pulmonary artery (RPA) and superior vena cava (SVC) visualization, with complete overlay at the most cranial border of their tight contact. B. Schematic representation of the lateral C-arm position (14–93° of leftward rotation; α1), and the resulting angiographic projection of the RPA and SVC, having minimal overlay. An introducer-sheath with a curved tip (104–180° of angulation relative to the SVC longitudinal axis; α3) is simulated within the SVC, with the end pointing to the SVC-RPA tightest contact area's cranial border. A ring with a dashed line schematically represents a snare within the RPA, in the vicinity of its contact with SVC. The profile and en face projections of the introducer-sheath within the SVC and the snare within the RPA in the posteroanterior and lateral views should give precise visualization of the course of the wire passing through the adjacent walls of the SVC and RPA at the cranial border of their tightest contact (or shortest distance between them), facilitating SVC-to-RPA stent deployment in a craniocaudal orientation. br.v: brachiocephalic vein; LPA: left pulmonary artery; mPA: main pulmonary artery RA: right atrium; tr: trachea.

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