Recanalization of occluded modified Blalock–Taussig shunt using topical recombinant tissue plasminogen activator with balloon angioplasty

ATHREE-YEAR-OLD GIRL WITH HETEROTAXY syndrome presented with severe cyanosis of 3 days duration, 14 months after construction of a left Glenn anastomosis and modified Blalock– Taussig shunt, during which a 4 mm Gore-tex graft had been interposed between the right common carotid artery and the divided right pulmonary artery.1 Emergency angiography (Fig. 1a), demonstrated complete occlusion of the shunt 5 mm beyond its attachment to the right common carotid artery (arrowhead), as well as the aftermath of multiple previous surgical and interventional procedures (repair of totally anomalous pulmonary venous connection, banding of the pulmonary trunk, and attempted total cavopulmonary connection). A Judkins right 1.5 coronary catheter (Create Medic, Yokohama, Japan) and a 0.032 J-shaped Radifocus guidewire (Terumo, Tokyo, Japan) were advanced through the occluded shunt. Lateral view of selective injection into the graft (Fig. 1b) showed thrombi floating in the proximal right pulmonary artery (arrowheads). Recombinant tissue plasminogen activator, in a dose of 2 104units/kg, followed by 5 104units/kg over 10 min, was given via a 4 French multi-purpose catheter (Mitsuya Medical, Yao, Japan). A repeated angiogram (Fig. 1c) now showed discrete thrombus in the proximal shunt (arrowhead). In order to increase the surface area for more effective thrombolysis, a 4 14 mm balloon (INVAtech, Besica, Italy) was Images in Congenital Heart Disease