A 23-year-old woman without a prior medical history presented with malaise, dyspnea, and massive edema of the lower limbs. Chest X-ray revealed a mediastinal tumor (Figure 1). The patient’s condition deteriorated drastically, with cardiogenic shock, hypoxia requiring mechanical ventilation, severe hepatic insufficiency (international normalized ratio, 6.8), and anuria. Pulmonary angiogram showed a 102 × 107 × 75 mm mass obstructing both pulmonary arteries (PAs; Figure 2). The patient’s pulmonary hemodynamic measurements were: right ventricular 50/6/18 mm Hg (systolic pressure/diastolic pressure/mean), PA 48/18/27, and right atrium 25/20/18, respectively. As a lifesaving procedure, percutaneous intervention of PAs was performed (Video 1). Because of technical difficulties, left PA was expanded only with balloon angioplasty (Figures 3A and 3B). Right PA was widened with implantation of two stents (Video 2). Improvement of blood flow was achieved (Video 3). Parameters gradually improved and symptoms resolved. Biopsy showed diffuse large B-cell lymphoma. After chemotherapy, complete remission was achieved and autogenous bone marrow transplant was performed.
Figure 1.
Chest X-ray showing a 102 × 107 × 75-mm tumor in the mediastinum.
Figure 2.
Contrast-enhanced chest computed tomography axial plane showing left pulmonary artery (PA) stenosis (2.5 mm in 34 mm) and right PA stenosis (5 mm in 40 mm).
Figure 3.
Contrast-enhanced chest computed tomography (CT). (A) CT axial plane showing an implanted stent in right pulmonary artery (PA) and residual stenosis in left PA. (B) Three-dimensional reconstruction of contrast-enhanced CT.
Video 1.
Pulmonary angiography. Critical narrowing in the proximal segment of the right and left pulmonary arteries. A pigtail catheter was introduced into the peripheral branch of the left pulmonary artery. The sheath was unable to be passed through the narrowing. Balloon dilatation was attempted several times but was unsuccessful. An attempt to implant a stent using the front-loading technique was ineffective. The procedure was abandoned.
Video 2.
Implantation of two stents on a balloon catheter in the right pulmonary artery. The long sheath curvature was impossible to cross with a long stent because of the size of the tumor. As a result, it was decided to implant 2 shorter stents.
Video 3.
Pulmonary angiography in the anterior–posterior view. Dilatation of the right pulmonary artery after implantation of two stents with good perfusion of the right lung. The left pulmonary artery remains narrowed after several unsuccessful attempts at balloon dilatation.
Stenosis within the pulmonary arterial tree is mostly caused by congenital heart disease (1–4). Adverse events (AEs) during treatment of congenital heart disease were documented in 22% of patients, with a high-severity AE in 10% of cases. The most common AEs were vascular/cardiac trauma (19%), technical (15%), and arrhythmias (15%). AEs were classified as not preventable in 50%, possibly preventable in 41%, and preventable in 9% (2). The interventional cardiologist had >10 years of experience, which reduced the risk for AEs. According to our best knowledge, this is the first case describing an intervention in a critically ill patient with PA stenosis without any AEs.
Supplementary Material
Footnotes
Author Contributions: E.T. is the treating physician and wrote the draft of the article; R.F. and A.W. are the treating physicians; P.A. and M.T.-S. assisted in writing the draft; P. Kurdyś, K.Ś., K.K., and P. Knapik critically revised the manuscript; and all authors read and approved the final manuscript.
The uncompressed videos are accessible from this article’s supplementary material page.
Originally Published in Press as DOI: 10.1164/rccm.201807-1366IM on February 26, 2019
Author disclosures are available with the text of this article at www.atsjournals.org.
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