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

Abstract

Patient: Female, 60Final Diagnosis: Pulmonary vein stenosis following single lung transplantSymptoms: Dyspnea on exertion and dry coughMedication: —Clinical Procedure: Balloon angioplasty and stenting of the left common pulmonary veinSpecialty: CardiologyObjective:Unusual clinical courseBackground:Pulmonary vein stenosis (PVS) is a rare event following lung transplantation, but is a serious complication that requires prompt diagnosis and treatment.Case Report:We describe the case of a 60-year-old woman who underwent single-lung transplantation for idiopathic pulmonary fibrosis (IPF). One year following her single-lung transplant, she was admitted to the hospital for hypoxemic respiratory failure. The results of quantitative lung perfusion scintigraphy (LPS) raised the possibility of a diagnosis of PVS. Computed tomography angiography (CT angiography) of the chest identified more than 50% stenosis of the left common pulmonary vein at the anastomotic site with the left atrium. She was successfully treated with angioplasty and stent placement guided by intravascular ultrasonography. Post dilatation of the PVS, the pulmonary venous pressure gradient decreased from 12–16 mm Hg to 3–4 mm Hg. At three-month follow-up, the patient reported resolution of her shortness of breath. In support of this case report, we review the management of four previously reported cases from the literature of lung transplantation associated with PVS.Conclusions:PVS should be considered in the differential diagnosis of lung transplant patients who present with worsening dyspnea. Quantitative LPS and CT angiography are important in the diagnosis of PVS. Successful management of PVS, with salvage of the transplanted lung and the prevention of further surgical interventions, may be achieved with intravascular ultrasound-guided angioplasty and stent placement.

Pulmonary vein stenosis after lung transplantation: a case report and literature review

“…There has been a total of 16 publications following 18 cases of PVS. This includes 10 case reports (3,5,(7)(8)(9)(10)(11)(12)(13)(14) and 6 retrospective studies (15)(16)(17)(18)(19)(20). These studies are summarized in Table 1.…”

“…Comparing the perioperative mortality rate of untreated PVS patients (1 of 2 patients, 50%) (9,17) with treated patients (2 of 17 patients, 11.8%) (3,5,7,8,(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), it is suggested that the risk of patient mortality may be decreased by timely diagnosis and appropriate intervention. Retransplantation or open surgical repair to relieve stenosis increases the patient's risk of death, while stent implantation with or without balloon dilation offers a less invasive treatment and seems to have been performed more in recent years.…”

“…Retransplantation or open surgical repair to relieve stenosis increases the patient's risk of death, while stent implantation with or without balloon dilation offers a less invasive treatment and seems to have been performed more in recent years. Data showed that PVS patients who received stent placement with/without balloon dilation showed excellent outcomes (3,5,11,12), while patients with balloon dilation as the only intervention method showed a high recurrence rate (13,14). At present, there is no uniform standard for stent size selection, which is mostly performed by clinicians based on their experience.…”

“…Clinically, the timely diagnosis of PVS is challenging and can often be missed because PVS presents with similar clinical symptoms to other post-transplant complications, such as reperfusion injury, infection, acute graft rejection and cardiac insufficiency (5). Currently, there are no clear guidelines on the optimal diagnostic modality and treatment of patients with PVS following lung transplantation.…”

Anastomotic complications after lung transplantation

“…Percutaneous angioplasty with or without vascular endoprothesis is usually successful, with low mortality and morbidity rates, for severe anastomotic stenosis of the pulmonary artery (55). In patients with complete venous obstruction, angioplasty with dilatation and endovascular stent placement may be useful (56), but, on occasion, re-transplantation or lobectomy may be required (57).…”