The Cabrol shunt or Cabrol fistula, also known as a perigraft-to-right atrial shunt, is a technique used for uncontrolled bleeding following aortic root operations.
The Cabrol shunt is applied when bleeding from an aortic root reconstruction cannot be controlled by traditional means (e.g. suturing, hemostatic agents). The principle of this shunt is to return shed arterial blood accumulating in the perigraft space automatically to the right atrium (or other venous site) 1,2. This technique decompresses the perigraft space, thus reducing tension on the suture lines, which may result in pseudoaneurysm formation 3. The shunt usually closes during the first postoperative week 4.
Early Cabrol shunts were performed to decompress the false lumen of an aortic dissection complicated by excessive hemorrhage 5. This was accomplished by draining blood from inside the aneurysm into the right atrium while using the classic Bentall technique to perform aortic root replacement. Nowadays, most surgeons have adopted aortic root replacement with direct coronary artery implantation, which leaves no residual tissue to wrap around the prosthetic graft to create a fistula. A pericardial pouch around the prosthetic graft is usually created. This produces a potential space (perigraft space) between the prosthetic graft and pericardial pouch. Several modifications to the Cabrol shunt, which include the use of autologous pericardium or dacron graft to serve as a shunt between the perigraft space and right atrium or other venous sites (e.g. brachiocephalic vein), have been reported 1,6-10.
The Cabrol shunt rarely stays open and may cause aorto-right atrial fistula (left-to-right shunt) that may result in pulmonary arterial hypertension and heart failure.
History and etymology
C Cabrol and colleagues first presented the concept of a perigraft-to-right atrial shunt in 1978 1,3. Since then, there have been several modifications to the procedure.
- 1. Elefteriades JA. Mechanism to Valve a Cabrol Fistula for Bleeding Control. Aorta 2013;1(1): 65–66. doi:10.12945/j.aorta.2013.13.012
- 2. Marcano HE, Garcia-Rinaldi R. Modified Cabrol shunt for uncontrollable hemorrhage after replacement of the aortic valve and ascending aorta. Ann. Thorac. Surg. 2009;87 (4): 1324. doi:10.1016/j.athoracsur.2008.10.084 - Pubmed citation
- 3. Kao CL, Chang JP. Perigraft-to-right atrial shunt for aortic root hemostasis. Tex Heart Inst J. 2004;30 (3): 205-7. Free text at pubmed - Pubmed citation
- 4. Okumu RO, O'Donnell D, McCreery CJ et-al. Cabrol shunt for iatrogenic aortic dissection: evaluation with cardiac 64-slice CT. Eur. Heart J. 2008;29 (5): 617. doi:10.1093/eurheartj/ehm437 - Pubmed citation
- 5. Cabrol C, Pavie A, Mesnildrey P et-al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J. Thorac. Cardiovasc. Surg. 1986;91 (1): 17-25. Pubmed citation
- 6. Muehrcke DD, Szarnicki RJ. Use of pericardium to control bleeding after ascending aortic graft replacement. Ann. Thorac. Surg. 1989;48 (5): 706-8. Pubmed citation
- 7. Blum M, Panos A, Lichtenstein SV et-al. Modified Cabrol shunt for control of hemorrhage in repair of type A dissection of the aorta. Ann. Thorac. Surg. 1989;48 (5): 709-11. Pubmed citation
- 8. Mancini MC, Cush EM. Shunt control of bleeding after homograft replacement of the ascending aorta. Ann. Thorac. Surg. 1999;67 (4): 1162-3. Pubmed citation
- 9. Posacioglu H, Apaydin AZ, Calkavur T et-al. Perigraft to right atrial shunt by using autologous pericardium for control of bleeding in acute type A dissections. Ann. Thorac. Surg. 2002;74 (4): 1071-4. Pubmed citation
- 10. Kitamura T, Kinoshita O, Ono M. Radical surgical repair with stepwise Cabrol shunt for severe prosthetic valve endocarditis. Interact Cardiovasc Thorac Surg. 2012;14 (5): 689-91. doi:10.1093/icvts/ivs033 - Free text at pubmed - Pubmed citation