Multidisciplinary Approach to Pulmonary Vein Compression by an Enlarging Vertebral Osteophyte
Presenter
Bogdan Kindzelski, MD, MSc, Cleveland Clinic Main Campus, Cleveland, OH
Bogdan Kindzelski, MD, MSc, Joanna Ghobrial, M.D., FSCAI, Gosta Pettersson, MD, PhD, Richard Schlenk, MD and Daniel Raymond, MD, Cleveland Clinic Main Campus, Cleveland, OH
Title
Multidisciplinary Approach to Pulmonary Vein Compression by an Enlarging Vertebral Osteophyte
Introduction
Osteophytes are osseous outgrowths along articular surfaces associated with degenerative changes. Rare cases have been described about intrathoracic structure compression by vertebral osteophytes. We present a unique case of right inferior pulmonary vein (RIPV) compression by a vertebral osteophyte.
Clinical Case
A 75-year-old male presented with worsening dyspnea on exertion and decreased exercise tolerance. His past medical history was notable for atrial fibrillation/flutter treated with multiple ablations, hyperlipidemia, pectus excavatum (Haller Index 4.9), and a previous left upper lobectomy for multiple pulmonary nodules 15 years ago. On CT scan, he was noted to have significant stenosis of his RIPV with gradual evolution in size of a corresponding vertebral osteophyte at the T8 level. He had a normal right hearth catherization. Subsequently, he underwent angiography of the RIPV which demonstrated an eccentric lesion with 80% narrowing and an 8mmHg gradient across the RIPV. A bare metal stent was placed and a completion angiogram demonstrated no residual stenosis with a gradient across the stent of 2mmHg. A follow-up CT scan demonstrated external stent compression and a subsequent repeat angiogram and RIPV stenting procedure was undertaken with the aim of providing more radial strength to prevent external compression. Completion angiogram showed no residual stenosis, however, a follow-up CT demonstrated extrinsic compression and narrowing of the peripheral aspect of the stents. Following a multidisciplinary case assessment by interventional cardiology, cardiothoracic surgery, and neurosurgery, the decision was made for surgical osteophyte excision with subsequent endovascular intervention. The patient underwent a right video assisted thoracoscopic approach and exposure of the culprit osteophyte with removal of the vertebral osteophyte. Subsequently, an angioplasty with a drug coated balloon was performed with angiography demonstrating excellent flow through the stented area. On his one and three-month follow-up CT scans, there was significant improvement of RIPV luminal stenosis without evidence of external compression. The patient reported symptomatic improvement as well as a mild improvement in his cardiopulmonary exercise testing was noted.
Discussion
Vertebral osteophytes are common, particularly in the elderly. Resultant complications are rare with the most frequent involving myelopathy and radiculopathy due to mechanical vertebral canal compression as well as dysphagia secondary to esophageal impingement. Intrathoracic compression of other structures with vertebral osteophytes rarely occurs. Sporadic cases of external compression of the trachea, bronchi, vertebral arteries, nerves, and left atrium have been reported. To our knowledge, we report the first isolated case of inferior pulmonary vein compression by a vertebral osteophyte as well as a successful treatment paradigm in a patient who had significantly altered mediastinal anatomy due to comorbid pectus excavatum and a previous lobectomy. Importantly, endovascular treatment alone with stenting failed as a primary intervention. After a multidisciplinary discussion, a minimally invasive approach to osteophyte removal with subsequent angioplasty of the stenotic region afforded the patient the best outcome, while avoiding a large open surgery and negating the need for cardiopulmonary bypass, stent removal, and pulmonary vein widening plasty.