An 11 year old boy was referred for surgical correction of tetralogy of Fallot, having undergone a palliative aortopulmonary shunt in eastern Europe seven years previously. Clinical examination revealed severe central cyanosis and a continuous shunt murmur, as well as a short ejection murmur from the right ventricular outflow tract. Selective angiography of the right subclavian artery demonstrated a direct anastomosis to the right upper pulmonary vein. From the clinical history he had been surprisingly well palliated for several years. The severe stenosis at the anastomotic site had protected the right lung from high pressure and pulmonary oedema, allowing successful repair.  Selective angiogram of the right subclavian artery (SA) in the frontal projection, demonstrated filling of the right upper pulmonary vein (PV) and subsequently the left atrium (LA). The arrow denotes the area of severe stenosis at the anastomotic site.

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