case_images: PMC11150795_01
case_images: Preoperative Doppler echocardiography at the shunt insertion. Color-flow Doppler examination from a right parasternal short-axis view (A,B) reveals a turbulent positive continuous shunt flow entering the distal right pulmonary artery (white arrow) (systolic, 4.18 m/s; diastolic, 2.56 m/s). Postoperative Doppler echocardiography at the preoperative location of the shunt. No residual flow was seen at the location (white arrowhead) (C,D).
case_images: fvets-11-1400076-g001.jpg
case_images: PMC11150795_01_fvets-11-1400076-g001.jpg
case_images: fig1
case_images: From the right parasternal short axis pulmonary artery view, a continuous L-to-R turbulent shunt flow distal to the right pulmonary artery (RPA) showing a mosaic pattern was identified on color Doppler, with a peak velocity of 4.18 m/s and a pressure gradient of 69.89 mmHg on continuous wave Doppler (Figures 1A,B). On postoperative echocardiography at 3 weeks and 12 weeks after surgical ligation, no residual shunting of the right pulmonary artery was observed (Figures 1C,D).
case_images: MIP images and a 3D reconstructed image of preoperative computed tomography scans. Scale bars equal 10 mm. Transverse 5-mm-thick slab MIP (A-C), dorsal 10-mm-thick slab MIP (D), sagittal 7.5-mm-thick slab MIP (E,F), and 3D reconstructed images of the heart and adjacent vessels (G). Shunt (black arrow) from the descending aorta at T8 level, which was considered the enlarged left bronchoesophageal artery (BEA) (A,E). Note that in (E), the shunt is supplying the periesophageal network (white dotted arrow). Tortuous vessels (white arrowhead) arising from the fifth and sixth dorsal intercostal arteries course forward and connect to the peritracheal network (black arrowhead) (B,F,G). On dorsal and transverse MIP images, the main shunt (white arrow) entering the distal right pulmonary artery (RPA) (black asterisk) is seen (C,D). 3D reconstructed image showing multiple tortuous vessels (white arrowhead), a network, and the main shunt vessel (white arrow) connected to the distal RPA (black asterisk). Note the aberrant tortuous vessel from the brachiocephalic trunk, which was considered the aberrant right BEA (black dotted arrow) (G).
case_images: fvets-11-1400076-g002.jpg
case_images: PMC11150795_01_fvets-11-1400076-g002.jpg
case_images: fig2
case_images: CT tomography revealed multiple L-to-R shunts (Figure 2). The first shunt (shunt 1) identified was a tortuous vessel originating from the brachiocephalic trunk that ran caudally and anastomosed with the peritracheal network (Figures 2E,G). The second shunt (shunt 2) was caudal to the first one, originated from the thoracic descending aorta at the T8 level, and formed tortuous vessels that eventually connected to the periesophageal network (Figures 2A,B,F). Regarding the third shunt (shunt 3), the vessels arising from the right fifth and sixth dorsal intercostal arteries joined and formed a tortuous shunting vessel that ran cranially and connected to the peritracheal network (Figures 2B-D,F,G). The measured size of the orifice was 4.1 mm at insertion (Figures 2D,G).
case_images: View at the time of surgical ligation of the shunting vessels. The main shunt entering the right pulmonary artery (white dotted line) is identified (A). The caudal vena cava is indicated by the black arrow. Blunt separation and ligation of the shunt are performed using a surgical clip (white arrow) and 5-0 polypropylene (B,C). Identification and ligation of the shunting vessel (yellow dotted line) from the brachiocephalic trunk:which was considered the aberrant form of the right bronchoesophageal artery and right fifth-sixth dorsal intercostal arteries:is performed, and a surgical clip (white arrowhead) is observed. The white asterisk indicates the reflection of the esophagus on the malleable retractor (D-F).
case_images: fvets-11-1400076-g003.jpg
case_images: PMC11150795_01_fvets-11-1400076-g003.jpg
case_images: fig3
case_images: An intercostal thoracotomy was performed at the 5th right intercostal space, and a shunt entering the right pulmonary artery branch was identified (Figure 3A). New Jersey, USA) (Figures 3B,C). Next, the shunts connected to the brachiocephalic trunk and the right 5th-6th dorsal intercostal arteries supplying the periesophageal network were identified, and ligation was performed (Figures 3D-F).
case_images: Follow-up computed tomography (CT) images at 12 weeks postoperatively (A-F) and a reconstructed 3D image (G) for comparison. Scale bars equal 10 mm. The remaining trunk of the ligated vessel (white arrow) connected to the right pulmonary artery, which is supplied by the peritracheal network (white dotted arrow), is identified, but no connection cranial to the surgical clip (white arrowhead, 1) is observed (A,B,C,G). Note the remarkable decrease in the flow of the peritracheal network (white dotted arrow) and the ligated vessel compared with those observed in preoperative CT (D,G). Surgical clip for the ligation of the small tortuous vessel originating from the fifth and sixth intercostal arteries, which were supplying the peritracheal network (white arrowhead, 2) (C). Ligation of the shunting vessel from the brachiocephalic trunk, which was considered the aberrant right bronchoesophageal artery (BEA) supplying the peritracheal network. No remaining flow after the ligation is observed. Surgical clips for the ligation of the suspected aberrant right BEA (white arrowhead, 3) and of the small shunting vessel originating from the fifth dorsal intercostal artery (white arrow, 2) (C-F).
case_images: fvets-11-1400076-g004.jpg
case_images: PMC11150795_01_fvets-11-1400076-g004.jpg
case_images: fig4
case_images: The shunting vessel anastomosed from the three shunts and the peritracheal-periesophageal network were observed; however, no connection between the aorta and the RPA was identified (Figure 4).