Types of Shunts

Several types of palliative shunts are recognized. An ideal shunt is expected to have the following attributes: Be rapid and technically simple to perform Provide adequate but not excessive pulmonary blood flow, hence minimizing the risk of congestive cardiac failure and pulmonary hypertension Provide good long-term patency Be technically easy to close when repair is completed Result in no residual cardiopulmonary abnormalities after closure

Although several modifications of a systemic-to-pulmonary artery shunt are known and are briefly discussed below, the modified Blalock-Taussig shunt is the most common type currently used. Classic Blalock-Taussig shunt The classic Blalock-Taussig shunt (CBTS) was the original operation described by Alfred Blalock and Helen Taussig and involves a direct anastomosis between the transected subclavian artery (or the innominate artery) and the pulmonary artery. As they described it, the operation was performed on the side opposite the aortic arch to minimize kinking of the subclavian artery as it crosses over the aortic prominence. In addition, the longer innominate artery reduces kinking of the pulmonary artery. The CBTS is an end-to-side anastomosis between the subclavian (or the innominate) and pulmonary arteries. It is performed in an extrapericardial fashion. One of the unique advantages of this shunt is the predictability of blood flow, because the subclavian artery diameter prevents excessive blood flow and, hence, congestive cardiac failure. For the same reason, this shunt is unlikely to cause pulmonary vascular disease. Other advantages include ease of closure during corrective surgery and potential adaptive growth of the anastomosis. One of the major disadvantages included thrombosis of the shunt due to its smallness. In addition, the mutilation of the subclavian or the innominate artery is a drawback of this procedure, although it did not appear to have a clearly significant clinical effect. Significant arm ischemia from subclavian artery division was uncommon, although the pulse in the ipsilateral arm was often not felt for days after the operation. Neurologic disadvantages are rare and include risk of recurrent laryngeal nerve injury, phrenic nerve injury, and Horner syndrome. Potts shunt A connection between the descending aorta and left PA, the Potts shunt was initially suggested as an alternate to the CBTS in neonates. It is easier to perform because it does not involve vessels of small caliber, such as the subclavian artery, thus resulting in a lesser incidence of shunt thrombosis and occlusion. It fell from favor because of the high incidence of subsequent pulmonary hypertension. Other reasons this shunt was abandoned include the preferential blood flow to one lung with kinking and distortion of the pulmonary artery and technical difficulties with takedown.

Waterston shunt This connection between the ascending aorta and right pulmonary artery is also no longer used because it has similar disadvantages to the Potts shunt (excessive pulmonary blood flow, risk of pulmonary hypertension). Congestive cardiac failure was reported in as many as 20% of patients with either of these shunts.17 Cooley shunt This is an intrapericardial anastomosis from the ascending aorta to the right pulmonary artery. The proposed advantages of this technique included using a right anterolateral thoracotomy incision for all approaches, avoiding mediastinal dissection (which could precipitate extrapleural bleeding from dilated collaterals), and using the same incision for other necessary surgical procedures (eg, complete repair). Furthermore, the anastomosis was created within the future operative field of total repair. This allowed closure of the palliative anastomosis without additional dissection during final repair. This shunt is no longer commonly used because technical aspects of this procedure were considered challenging, and construction of an improperly sized anastomosis could lead to heart failure and pulmonary congestion. In addition, because the pericardium is invaded, the patient is at higher risk for adhesions in the region of future cardiac repair. Modified Blalock-Taussig shunt The modified Blalock-Taussig shunt (MBTS) is currently the modification most commonly used. In 1962, Klinner originally described the procedure, which others subsequently detailed. 18 The authors proposed this operation to prevent the mutilating effects of the CBTS. The latter group also indicated that the MBTS is useful when CBTS cannot easily be performed, such as on the same side as the aortic arch. They also maintained that pulmonary artery distortion is less likely than with CBTS. Closure of these shunts is also technically easy. An interposition polytetrafluoroethylene (PTFE, or Gore-Tex) graft between the subclavian artery and the pulmonary artery is used to prevent sacrificing the subclavian artery. PTFE was found to be superior to Dacron because it has a smaller pore size that limits the tissue ingrowth but allows for fibroblastic incorporation to bind it to surrounding structures.19 Excellent patency rates of 90% at age 2 years have been reported. 19 They advocate using shunts of at least 5 mm, even in small infants, arguing that the orifice of the subclavian artery serves to regulate blood flow through the shunt. Rare reported complications include leakage of serous fluid through the PTFE in the chest and pseudoaneurysm formation, which can cause massive fatal hemoptysis.