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Congenital heart disease
Interventional catheterisation. Opening up II: venous return, the atrial septum, the arterial duct, aortopulmonary shunts, and aortopulmonary collaterals
  1. John L Gibbs
  1. The Yorkshire Heart Centre, Department of Paediatric Cardiology, Leeds General Infirmary, Leeds, UK
  1. Dr John L Gibbs, The Yorkshire Heart Centre, Department of Paediatric Cardiology, E Floor, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK email: jgibbs{at}ulth.northy.nhs.uk

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Obstruction to flow in the superior caval vein rarely occurs de novo. It is usually a consequence of scarring related to surgery, to the presence of venous catheters or pacemaker electrodes, or external compression by tumour. When obstruction occurs insidiously there may be no symptoms and no indication to intervene, but with rapid onset obstruction, when collateral veins have not had time to develop and enlarge, venous hypertension in the head and neck will prompt treatment (fig 1). Although these stenoses can be dilated using a balloon, stent implantation is usually required to prevent recoil.1 Self expanding as well as balloon expandable stents have been used with good effect. In the presence of complete obstruction “reconstruction” is sometimes possible by passing a long needle and then a guide wire through the obstruction, followed by ballooning and stenting. Because the vein is usually surrounded by scar tissue accidental perforation is unlikely to cause any more harm than localised haematoma.

Figure 1

(A) Severe, symptomatic obstruction of the superior caval vein, with multiple small collateral channels, in a child who had undergone cardiac transplantation following numerous palliative operations for complex congenital heart disease. There was little improvement after simple balloon dilatation (using axillary venotomy), but stent implantation (B) produced complete relief of obstruction.

Intra-atrial obstruction to systemic venous return may occur after venous inflow redirection surgery for transposition of the great arteries. This is relatively common after Mustard's operation, when patches of material are sewn inside the atria to redirect the systemic veins to the left atrium and the pulmonary veins to the right atrium (fig 2). Obstruction is much less likely after Senning's operation, in which redirection is achieved using infoldings of the atrial wall. Obstruction may become evident many years after surgery (during teenage or adult life) and often presents …

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