Troubled Judging of Bronchus Compression Due to Contrast-Filled Balloon in Three-Dimensional Rotational Angiography.

Abstract

Three-dimensionalrotational angiography (3DRA) is a suitable technique to detect the risk of left main bronchus (LMB) compression during left pulmonary artery (LPA) stenting in partial cavopulmonary connection and total cavopulmonary connection (TCPC). We report on a case of a 4-year-oldboy with hypoplastic left heart syndrome and TCPC in which 3DRA and bronchoscopy gave conflicting information on airway patency during balloon interrogation. The balloon with high contrast concentration created a severe artifact impeding visibility of the LMB. Simultaneous flexible bronchoscopy revealed an unobstructed LMB.Repeated3DRAs with lower contrast concentration had no artifact and showed a patent airway in accordance with the bronchoscopy.Conventional LPA stenting was performed without indication for stent ovalization.The benefit of low contrast concentration in the interrogation balloon was demonstrated in a second case of an 11-year-old boy with TCPC. The margins of the LPA and LMB were clearly visible without blank-out artifact. Oval stent procedure was necessary to prevent LMB compression. When 3DRA is used for vessel-airway interrogation, the balloon contrast concentration should be low in order to avoid artifacts. When in doubt, simultaneous flexible bronchoscopy can overcome the dilemma in airway judgment.