Pulmonary Vein Stenosis After Lung Transplantation Successfully Treated With Stent Implantation
A 31-year-old white woman with end stage idiopathic pulmonary fibrosis underwent left lung transplantation in our institution in January 2010. Oxygenation could be preserved by the native right lung, so surgery was performed without cardiopulmonary bypass. The procedure was uneventful and a bronchoscopic assessment of the graft showed only mild edema of the mucosa.
In the early postoperative course gas exchange was difficult to maintain, requiring high FiO2 and positive end-expiratory pressure. Chest x-ray demonstrated alveolar infiltrates in the graft (Figure 1A). Due to the suspicion of reperfusion edema, an infusion of furosemide was initiated, although only a partial resolution of the congestion was achieved. The patient was successfully extubated 5 days after intervention, however reintubation was needed within 24 hours due to desaturation and inadequate response to noninvasive ventilation. At this time point a bronchoscopic evaluation was carried out. Biopsies of the graft revealed no signs of acute rejection, but microbiological test of the transbronchial lavage showed Staphylococcus epidermidis infection. IV teicoplanin was administrated for 7 days, but no significant change in the clinical status or chest x-ray was found. A transesophageal echocardiography (TEE) conducted 11 days after transplantation revealed a severe stenosis at the sutures of left pulmonary veins atrial cuff anastomosis (Figure 2A and 2B) with a peak gradient across the obstruction of 25 mm Hg (Figure 2C). Contrast medium enhanced computed tomography (CMECT) confirmed the findings (Figure 3A and 3B). A percutaneous interventional approach with stent implantation was decided and performed 15 days after surgery. A 4F multipurpose catheter (Vista 4F JR 4SH; Cordis, Miami Lakes, Fla.) was positioned in the left atrium via the right femoral vein following transseptal puncture. The atrial cuff anastomosis was located with angiography measuring a maximum 20 mm Hg gradient across. Guided by 3D TEE, a Ø10-mm/19-mm-long bared metal stent (Palmaz Genesis; Cordis J&J Interventional Systems Co., Warren, NJ) was successfully delivered without balloon predilatation (Figure 4A through 4C), reducing peak echo and invasive gradients to 2.5 and 5 mm Hg, respectively.
A rapid improvement in the clinical situation and graft congestion was seen during postinterventional course; respirator weaning was rapidly achieved and chest x-rays showed complete resolution of the edema within 5 days (Figure 1B). Patency of the stent was demonstrated by TEE and CMECT 1 week after the percutaneous procedure (Figure 5A through 5C). Following a previous experience,1 antithrombotic therapy with 150 mg of aspirin and 75 mg of clopidogrel for 6 months and acenocoumarol to maintain a international normalized ratio of 2 to 3 for 3 months was prescribed. The patient was discharged 20 days after stent implantation without supplementary oxygen.
Severe pulmonary vein stenosis is a rare complication after lung transplantation. The diagnosis is challenging as it mimics other frequent causes of alveolar infiltrates such as reperfusion edema, rejection, or infections. Bearing in mind that without adequate treatment, pulmonary vein stenosis may lead to graft failure, evaluation of vascular anastomosis should be taken into account when such conditions have been ruled out. TEE should be considered as the first step. CMECT or magnetic resonance imaging should be used to verify the diagnosis or when TEE is not available. Therapeutic options have not been adequately established. Few cases of percutaneous intervention with promising results have been reported.1,2
- © 2010 American Heart Association, Inc.