Percutaneous dilatation of right inferior pulmonary vein stenosis following single-lung transplant

Abstract

We present a 62-year old male who underwent right single-lung transplantation. An autologous pericardial rim was constructed at implantation, as there was insufficient donor atrial cuff. The patient was discharged home but deteriorated over 12 months resulting in oxygen dependency. Computed tomography scan showed stenosis of the right inferior pulmonary vein. The patient underwent pulmonary vein angioplasty under general anaesthesia in September 2007, which was successful and resulted in significant improvement in clinical status. However, his symptoms recurred 2 months later and a second attempt at angioplasty failed. He died 6 weeks later. Keywords: Vein restenosis • Anastomosis • Lung transplantation CASE REPORTWe present the case of a 62-year old man who underwent right single-lung transplantation for usual interstitial pneumonitis (UIP) on 31 August 2006. The UIP was associated with 'SS' phenotype of alpha-1 antitrypsin deficiency. The patient had both physiological and radiographical findings, consistent with a mixed restrictive and obstructive pattern. His only significant medical history was osteoporosis, secondary to steroid usage.Right single-lung transplantation was performed on cardiopulmonary bypass as the patient had moderate pulmonary hypertension. The donor lung was found to have a deficient left atrial cuff with six small vein orifices and minimal atrial cuff tissue infero-posteriorly. This was repaired using an autologous pericardial patch with 4/0 prolene to create suitable rim for anastomosis to the recipient left atrium. This neo-cuff subsequently formed three quarters of the circumference of the anastomosis with the donor LA forming the other quarter ( Figs. 1 and 2). At the end of the procedure, good drainage was confirmed by transoesophageal echocardiogram (TOE), and the patient came off bypass easily with good gas exchange.Early postoperative recovery was uncomplicated. He was started on a calcineurine inhibitor, mycophenolate mofetil and prophylaxis for Pneumocystic Carinii Pneumonia (PCP)/cytomegalovirus (CMV). Over the following 12 months, the patient's respiratory function deteriorated and he became bed-bound and oxygen dependent. He was treated for CMV pneumonitis and aspergillosis. Computed tomography (CT) scanning demonstrated a stenosis at the level of the right inferior pulmonary vein (RIPV) where the vessel measured 2 mm in diameter. The CT scan also demonstrated areas of pulmonary venous infarction upstream of the stenosis. In view of his clinical state, he was considered to be too high risk for surgical intervention.It was, therefore, decided to attempt percutaneous dilatation of the stenosed RIPV. This was performed under general anaesthesia (GA) with TOE and fluoroscopic guidance. Access was gained to the right atrium via the right femoral vein and transseptal puncture was performed with a Brockenbrough Needle (Medtronic, MA) and a 9F-Preface sheath (Biosense Webster, CA). Access to the RIPV from the trans-septal puncture was difficult and, ultimately, the RIPV was ...

Endovascular transatrial stenting of pulmonary vein stenosis after lung transplantation

“…(Table1) [3][4][5][6][7][8]11,12 . Most common clinical presentations were respiratory insufficiency, pulmonar y edema or pleural effusion.…”

Pulmonary Vein Stenosis Following Single-Lung Transplantation Successfully Treated with Intravascular Ultrasound-Guided Angioplasty and Stent Placement

“…Mydin et al described the case of a 62-year-old man who had right PVS following a single-lung transplantation for IPF [ 6 ]. In this case, balloon angioplasty was performed, but stenting was unsuccessful due to technical issues, and the patient’s symptoms recurred after two months [ 6 ]. Gaubert et al reported a patient with left pulmonary artery stenosis, which recurred with balloon angioplasty alone [ 7 ].…”