Simultaneous Triple Balloon Angioplasty to Maintain Patency of All Lobes and Segments in Severe Pulmonary Vein Stenosis
Presenter
Conor O'Halloran, M.D., Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, IL
Conor O'Halloran, M.D.1, Jeremy Fox, M.D.2, Dr. Paul Tannous, M.D., Ph.D., FSCAI2 and Alan W. Nugent, M.B.B.S., FSCAI2, (1)Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, IL, (2)Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
Title:
Simultaneous triple balloon angioplasty to maintain patency of all lobes and segments in severe pulmonary vein stenosis
Introduction:
Pulmonary Vein Stenosis (PVS) interventions are long and complex procedures. In severe cases, the initial intervention focuses on preserving all lobes with aggressive angioplasty and stenting. Subsequent interventions aim to maintain patency of existing stents and treat additional lesions to ensure adequate drainage of all major segment of each lobe. In this context great care must be taken to maintain the integrity of existing stents when treating additional lesions.
Clinical Case:
A late-preterm infant male with ventricular septal defect and bilateral PVS was scheduled for surgery but developed acute respiratory failure at 6 months of age and 6kg requiring urgent extracorporeal membrane oxygenation (ECMO). Four PV stents: right upper (RU), right middle (RM), left upper (LU) and left lower (LL) were placed with simultaneous with emphasis on the distal stent being in the largest segmental branch and avoiding stent material into the left atrium. ECMO decannulation the next day and eventual surgical VSD closure were achieved.
At 9 months a scheduled repeat PVS rehabilitation was performed. Bilateral femoral venous access was achieved with 6.5Fr-steerable and 4Fr long sheaths. The RVp was 75% systemic with normal cardiac index. Pulmonary artery wedge angiograms proved patency with in-stent stenosis (ISS) of the RUPV and RMPV stents. From the initial intervention there were 2 major segmental RMPV branches, and the anterior segmental branch was jailed. The LUPV stent was into the lingular segment and jailed LUPV segments. RLPV stenosis was confirmed. The RUPV stent was crossed with a sheath, catheter, microcatheter and 0.014” wire combination. Via the steerable long sheath two 0.014” wires were placed through the RMPV stent, one into the existing stent lumen and the other through a side cell to the jailed anterior segment. Three coronary balloons were advanced into position and simultaneously inflated across the RUPV stent, the RMPV stent, and the side cell of the RMPV stent to dilate all stenotic segments without compromising other lobes or segments. Repeat angiography showed unobstructed flow across the RUPV stent with good flow to jailed RUPV segments and unobstructed flow to both RMPV segments. Utilizing a similar technique, simultaneous triple balloon inflation was also use to improve flow to the jailed apical LUPV segment while maintain LUPV/Lingular stent integrity and LLPV stent integrity. Additional interventions were also performed on the RLPV with 2 simultaneous stents placed. Follow up echocardiogram 2 days after intervention showed RVp 27% systemic.
Discussion:
Pulmonary vein stenosis is a progressive disease which requires early, aggressive, and repeated interventions. Complex multi-vessel pulmonary vein disease requires staged interventions to preserve all major segments and maintain stent patency. Attention to high quality PA angiograms is required to identify jailed pulmonary vein segments that may not be seen on venous angiography and may require intervention. Simultaneous inflations of multiple balloons may be required to protect existing stents when performing addition interventions.