Progressive Pulmonary Venous Stenosis and Recurrent Hypoxemic Respiratory Failure in a Lung Transplant Recipient

Abstract

<h3>Introduction</h3> Pulmonary venous stenosis (PVS) is a rare complication of lung transplant (LT) that typically presents soon after surgery with pulmonary congestion at the site of reduced venous drainage. We describe a case of a 34-year-old LT recipient with an unremarkable initial postoperative course who later developed recurrent hypoxemic respiratory failure due to progressive PVS. <h3>Case Report</h3> The patient underwent an uneventful bilateral LT; he had no evidence of primary graft dysfunction, was extubated the day after LT, and was discharged 10 days later. A month after LT, a chest CT showed moderate narrowing of the right superior pulmonary vein (RSPV); the remaining PVs appeared unremarkable. A subsequent chest CT showed mild right interlobular septal thickening and an incidental left bronchial anastomotic dehiscence. He recovered from dehiscence repair but continued to present with intermittent respiratory failure and bilateral, lower lobe predominant, ground-glass opacities and consolidations. As the location of the consolidations did not correlate with the location of PV narrowing, pulmonary edema from reduced venous drainage was not suspected. However, CT5 months after LT showed increased narrowing of the RSPV as well as narrowing of the right inferior pulmonary vein (RIPV) and left superior and inferior pulmonary veins (LSPV, LIPV); follow-up CT showed complete absence of opacification of the right venous system. In collaboration with interventional cardiology, PV stenting was selected over re-transplant. A 3-D model of the patient's proximal pulmonary vasculature was printed to guide intervention. Angiography at 16 months after transplant revealed occlusion of the RSPV and RIPV, severe stenosis of the LIPV, and moderate-severe stenosis of the LSPV (6-7mm). A transseptal approach was used to perform balloon angioplasty with stenting (Palmaz biliary stents) of the LSPV first and the RIPV 3 months later. The patient was treated with dual anti-platelet therapy, reported significant symptomatic improvement, remains off of supplemental oxygen, and still has stable allograft function 21 months after PV stenting. <h3>Summary</h3> PVS is a well-described postoperative complication of LT; however, progressive stenosis of multiple PVs is unusual. PV stenting can improve venous drainage and relieve pulmonary congestion in patients with progressive PVS.