5 year old girl underwent surgical repair of VSD with pulmonary atresia. Pre operative cardiac CT angio revealed confluent good sized pulmonary arteries, small collaterals from descending aorta and a patent BT shunt. Based on CT findings patient was taken up for total correction.
Post operative period was complicated by repeated episodes of pulmonary hemorrhage, presenting as frank ET bleeds.
On cardiac catheterization 2 collaterals were seen arising from descending aorta, there were no collaterals from the left subclavian artery. The right subclavian artery angiogram revealed leash of arising from its entire length and feeding the upper lobe of right lung. The collaterals from descending aorta were embolised using Cook coils, nothing was done for the vessels arising from subclavian artery.
The pulmonary hemorrhage continued.
Options available:
1. Covered stent in the subclavian artery to exclude all the collaterals
2. Ligation of subclavian artery -
3. Occluding the subclavian artery distal to origin of Carotid artery

Covered Stents of the required size were not available, Either of the other two procedures could lead to of limb ischemia. Mean while patient continued to have recurrent pulmonary bleeds. Finally therapeutic occlusion of right subclavian artery was done using a vascular plug and a Cook coil. This along with factor V transfusion, were able to control the pulmonary hemorrhage and patient could be extubated.
Except for loss of pulse in the right arm, no other immediate side adverse effects were noted.
Message:
Cardiac cathterization and coil occlusion of collaterals should be done pre-oparatively