Case Report of a Gore-Tex TCPC conduit dissection causing severe stenosis

Background The patient is a 15-year-old male with situs inversus, dextrocardia, bilateral superior caval veins, atrioventricular discordance with a single outlet, large perimembranous ventricular septal defect, aortic override, pulmonary atresia and right aortic arch. The complex anatomy with a VSD distant from the aorta (unsuitable for baffling to the aorta) meant he was unsuitable for biventricular repair and proceeded down a univentricular palliation pathway. Case Summary Post TCPC his clinical course was uneventful until the age of five when he developed fatigability with desaturation. An accessory hepatic vein was surgically banded with improved saturations and exercise tolerance. At the age of fifteen CMR was performed to investigate borderline saturations and as work up for transition to adult services. CMR and cardiac CT imaging demonstrated an eccentric thrombus causing stenosis of the extra cardiac conduit and a thrombus outside of the lumen contained by the thin outer membrane of the Gore-Tex conduit. Collateralisation suggested this was longstanding. Cardiac catheterisation demonstrated a 4x6mm stenosis at the junction of the conduit with the pulmonary arteries. The region was successfully balloon dilated and stented with a 34 mm-long Cheatham Platinum (CP) stent, with no complications. Discussion To date this is the first documented case of a dissecting thrombus of a Gore-Tex graft in the literature. This case emphasises the need for anticoagulation and serial cross-sectional imaging (CT or CMR) in Fontan patients with prosthetic grafts throughout a patients’ lifetime.

NUMBER AND PATTERN OF HEPATIC AND ACCESSORY HEPATIC VEINS

Introduction: Liver receives dual blood supply from hepatic artery and portal vein. Venous blood from Liver to inferior vena cava is drained by three hepatic veins. The number, pattern and mode of termination of hepatic veins into inferior vena cava is not always same. Variations in number, pattern and positions of the hepatic veins and their mode of termination do exist which significantly influence surgical interventions on liver especially during transplantation. Materials and Methods: 28 wet formalin preserved specimens were taken for the present study. A longitudinal incision was given in the inferior vena cava to observe the number, pattern and arrangement of hepatic veins openings into inferior vena. The specimens were preserved after routine dissection classes Result: 19 livers of 28 (67.86%) were found to be drained by three major hepatic veins, whereas 9 livers out of 28 (32.14) presented with accessory hepatic veins in addition to major hepatic veins. The number of accessory veins ranged from 1-3. Out of the nine specimens with accessory hepatic veins seven (77.77%) presented with three plus one pattern (3 major hepatic veins 1 accessory hepatic vein).Three plus two and three plus three pattern was observed in one specimen each (11.11%). The arrangement of three major veins from left to right was left hepatic, middle hepatic and right hepatic. The openings of all accessory veins were found below the openings of major hepatic veins. Conclusion: A sound knowledge of Accessory hepatic veins and their pattern is essential for Radiologists and also for liver transplant surgeons to reduce postoperative complications.