A bleeding Blalock–Taussig shunt

 

Since birth, an 8-month-old child has had truncus arteriosus, a left pulmonary artery sling (Panel A), and tracheal stenosis. She received an operation for main pulmonary artery division from truncus, right modified Blalock-Taussig (mBT) shunt, and sliding tracheoplasty at the age of 13 days due to complex pulmonary artery anatomy and bilateral pulmonary artery hypoplasia. Cardiogenic shock due to blockage of the mBT shunt occurred two weeks after surgery. Right mBT shunt revision and fresh left mBT shunt implantation were conducted after extracorporeal cardiopulmonary resuscitation. She was discharged home with a tracheostomy at the age of 7 months after an extended stay in the hospital for post-resuscitation complications. After a month, the patient was readmitted due to respiratory discomfort and a high temperature. At the time of admission, the patient was moderately anaemic (haemoglobin was 11.3 g/dL), and his blood pressure was 94/40 mmHg. Bacteremia caused by Burkholderia cepacia was later proven. Surprisingly, a continuous colour flow jet was discovered at the confluence of the left subclavian artery and the left mBT shunt on follow-up echocardiography. Around the left mBT shunt, the swirling jet flowed into an aneurysm-like area (Panel B, Supplementary material online, Videos S1 and S2; star indicates pseudoaneurysm; arrow indicates flow jet of the bleeding site; arrowhead indicates the mBT shunt). 

The patient had a ruptured left mBT shunt with ongoing bleeding and pseudoaneurysm development. The filling contrast in a partially thrombosed huge pseudoaneurysm around the left mBT shunt was seen on computed tomography (Panel C, Supplementary material online, Video S3; star indicates pseudoaneurysm; arrow indicates flow jet of the bleeding site; arrowhead indicates the mBT shunt) and 3D reconstruction (Panel D, Supplementary material online, Video S4). Surprisingly, despite the fact that active bleeding remained for more than a month in subsequent follow-up, it appeared to be effectively contained inside the pseudoaneurysm with no major haemodynamic damage. We decided on palliative care after consulting with her family.