| Summary: | HOW WOULD I APPROACH IT? There is no doubt that, procedurally, the case of fistulization reported between the pulmonary artery trunk and the right pulmonary branch is an interesting case similar to common situations reported in the routine clinical practice where pulmonary trunk surgical ligation is not complete thus leaving residual passage between the heart and Fontan circulation. This is unsought because it sends already oxygenated blood back to the lung, which overloads a circulation so sensitive as the Fontan one that lacks heart pump and works through venous pressure gradient. In this type of procedures, closing the junction between the branch and the pulmonary trunk is often enough. Different strategies exist for this purpose. First, we need to think about the approach that should be used to close the defect. In this case, although the existence of fenestration (communication between Fontan circulation and the systemic atrial region) facilitates occlusion using the antegrade (through the ventricle) and retrograde (coming from the pulmonary artery) approaches, the latter is often easier and faster to use. Procedure can be performed via femoral access. The bigger the patient the easier the procedure. However, in very small patients, it is often easier to perform via jugular access...
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