Treatment Of Pulmonary Artery Stenosis Research Articles

Multimodality imaging and hybrid treatment of pulmonary artery stenosis in a patient with a high risk of airway compression.

Multimodality imaging and hybrid treatment of pulmonary artery stenosis in a patient with a high risk of airway compression.

B-35 | Comparison of Premounted Drug Eluting Stents vs. Non-Eluting Stents for the Treatment of Pulmonary Artery Stenosis In Smaller Patients

Small patients with congenital or post-operative pulmonary artery stenosis (PAS) often require multiple catheterizations. Frequently, balloon angioplasty results in only temporary improvement and occasionally, stenting is necessary. Pre-mounted stents have a low profile and are easier to advance in this population, and recent evidence has shown some of these stents can be fractured longitudinally with high pressure balloons allowing for further growth potential. However, restenosis is common in bare metal stents.

Pulmonary artery pathologies in Alagille syndrome: a meta-analysis

Alagille syndrome, caused by mutations in the gene encoding Jagged1 (JAG1), a ligand in the Notch signaling pathway, is an autosomal dominant disorder with developmental abnormalities affecting the liver, heart, eyes, face and skeleton. The aim of the present study is try to disclose the clinical features, management and outcomes of pulmonary artery stenosis associated with Alagille syndrome. By comprehensive literature retrieval, 38 articles involving 401 patients were recruited for this study. The pertinent variables closely related to pulmonary artery stenosis in patients with Alagille syndrome were comprehensively analyzed by following the PRISMA guidelines. The management of pulmonary artery pathologies, especially a severe type of pulmonary artery stenosis in Alagille syndrome, is a concerned matter. Publications of literature retrieval of recent 3 decades were the study material of this article. The pulmonary artery pathologies, especially the severe type of pulmonary artery stenosis in Alagille syndrome, warrant surgical or interventional treatments. After the procedures, the right ventricular to left ventricular pressure ratio was reduced by 25%. There were no intergroup differences in terms of recovery, reintervention and mortality rates between interventionally and surgically treated patients. Transcatheter treatment is preferable due to less trauma. Surgical treatment of pulmonary artery stenosis can be performed currently with intracardiac defect repair.

Personalized stent design for congenital heart defects using pulsatile blood flow simulations

Stent size selection and placement are among the most challenging tasks in the treatment of pulmonary artery stenosis in congenital heart defects (CHD). Patient-specific 3D model from CT or MR improves the understanding of the patient’s anatomy and information about the hemodynamics aid in patient risk assessment and treatment planning. This work presents a new approach for personalized stent design in pulmonary artery interventions combining personalized patient geometry and hemodynamic simulations. First, the stent position is initialized using a geometric approach. Second, the stent and artery expansion, including the foreshortening behavior of the stent is simulated. Two stent designs are considered, a regular stent and a Y-stent for bifurcations. Computational fluid dynamics (CFD) simulations of the blood flow in the initial and expanded artery models are performed using patient-specific boundary conditions in form of a pulsatile inflow waveform, 3-element Windkessel outflow conditions, and deformable vessel walls. The simulations have been applied to 16 patient cases with a large variability of anatomies. Finally, the simulations have been clinically validated using retrospective imaging from angiography and pressure measurements. The simulated pressure, volume flow and flow velocity values were on the same order of magnitude as the reference values obtained from clinical measurements, and the simulated stent placement showed a positive impact on the hemodynamic values. Simulation of geometric changes combined with CFD simulations offers the possibility to optimize stent type, size, and position by evaluating different configurations before the intervention, and eventually allow to test customized stent geometries and new deployment techniques in CHD.

Single Lung Transplant Complicated by Anastomotic Pulmonary Artery Stenosis

SESSION TITLE: Transplantation SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Anastomotic pulmonary artery stenosis after lung transplantation is a rare complication. Endovascular stenting appears to be a safe and efficacious treatment modality1. CASE PRESENTATION: A 43-year-old female with COPD underwent a single left lung transplant. Four months post-transplant, she presented with progressive hypoxic respiratory failure. CT chest showed a new ill-defined 2.2 x 2.1 cm nodular opacity in the left lower lobe graft shown in Figure 1. Transbronchial biopsy was negative for rejection. Bronchoalveolar lavage showed Aspergillus antigen index of 7.56 and culture grew 1 colony of non-sporulating filamentous fungus. CT-guided biopsy of the lesion showed necrotic lung parenchyma. She was treated empirically with intravenous and inhaled Amphotericin B. Despite treatment, her respiratory failure worsened and she became heated high flow oxygen dependent. Quantitative nuclear lung perfusion scan showed an overall perfusion to the right native lung was calculated to be 77.04% with overall perfusion to the left graft lung calculated to be 22.96%. Right heart angiography confirmed significant stenosis of the left pulmonary artery shown in Figure 2. Placement of a 26 mm x 12 mm LD Mega stent resulted in minimal residual stenosis. Repeated nuclear lung perfusion showed overall perfusion of left graft lung increased to 57.34%. She was eventually discharged home on room air. DISCUSSION: Pulmonary artery stenosis is a rare complication after lung transplantation. It requires a high index of suspicion especially after ruling out rejection and infection etiologies. Open repair carries high mortality and morbidity risk. To date, there have been a few case reports and retrospective studies to support the safety and efficacy of percutaneous endovascular stent placement2. Our patient tolerated the procedure well and had significant clinical improvement. CONCLUSIONS: Percutaneous endovascular stent placement is gaining acceptance as the first choice treatment for pulmonary artery stenosis following lung transplant since it is better tolerated than open repair. It appears to be safe and efficacious. However, long-term outcomes are not clear at this point. Reference #1: Grubstein A et al. Angioplasty using covered stents in five patients with symptomatic pulmonary artery stenosis after single-lung transplantation. Cardiovasc Intervent Radiol, 2014; 37: 686-690. Reference #2: Anaya-Ayala JE et al. Endovascular management of early lung transplant-related anastomotic pulmonary artery stenosis. J Vasc Interv Radiol, 2015; 26: 878-882. DISCLOSURE: The following authors have nothing to disclose: Van Le, Amy Pope-Harman No Product/Research Disclosure Information

Hybrid Pulmonary Artery Stenting at the Bidirectional Glenn or Fontan Operation in Patients With Single Ventricle Congenital Heart Disease

Stenosis of the retroaortic pulmonary artery is common in patients with single ventricle heart disease. Intraoperative hybrid stenting at the bidirectional Glenn or Fontan operation can treat this lesion and avoid a complex surgical arterioplasty. Patients who underwent intraoperative stent implantation to the retroaortic pulmonary artery during the bidirectional Glenn or Fontan operation at our center between January 2005 and July 2014 were retrospectively identified. Thirteen patients were included with a median weight of 8 kg (5.6-14.4 kg) and age of 6 months (4 months-3.8 years). All had undergone Norwood operation, and eight (62%) had hypoplastic left heart syndrome. Eight (62%) underwent stent placement during bidirectional Glenn and five (38%) during Fontan operation. Ten patients had one stent placed, and three had two overlapping stents. The median diameter of the stenotic vessel was 3 mm (2.0-5.5 mm) and diameter of the balloon used for stent expansion was 7 mm (5-10 mm). Two complications occurred including pulmonary hemorrhage from presumed wire perforation and left main stem bronchus compression requiring stent removal. No patient required stent intervention in the postoperative period, and all were discharged from the hospital. At a median follow-up of 1.3 years (2 months-7.1 years), six patients underwent interval dilation to account for somatic growth. Hybrid stenting of the retroaortic pulmonary artery at the bidirectional Glenn or Fontan operation is an effective treatment of pulmonary artery stenosis and prevents the need for a complex surgical arterioplasty.

Impact of Percutaneous Interventions for Pulmonary Artery Stenosis in Alagille Syndrome

The study aims to examine acute and midterm outcomes after percutaneous interventions for treatment of pulmonary artery stenosis (PAS) in patients with Alagille Syndrome (ALGS). PAS affects up to two thirds of ALGS patients. Responsiveness to transcatheter therapies may differ from other causes of PAS. To date, there has been no study to evaluate outcomes of transcatheter interventions on PAS exclusively in ALGS. In this single-center series, we reviewed procedural, hemodynamic, and angiographic data from patients with ALGS and PAS from 2007 to 2011 who underwent an interventional catheterization. Minimal luminal diameter (MLD) was assessed pre- and postintervention, and at follow-up catheterization(s) when available. Acute and midterm response to high-pressure balloon angioplasty (HBA), bare metal stent (BMS) placement, and cutting balloon angioplasty (CBA) were assessed. Nine patients (median age 9.1 years) underwent 16 cardiac catheterizations with 34 interventions performed (20 HBA, 11 BMS, 3 CBA). There was a significant acute increase in MLD for all three modalities (42% HBA, P < .01; 91% BMS, P < .01; 58% CBA, P = .04). Follow-up data were available for 19 treated lesions at a median of 11 months. There was no significant difference in the improvement of MLD from baseline between the HBA and BMS groups, although in contrast to the BMS group, the HBA group showed continued interval vessel growth. Transcatheter intervention for PAS in ALGS is generally safe and acutely effective. Although BMS implantation was associated with the greatest immediate improvement in MLD, HBA-treated vessels demonstrate interval growth, whereas BMS-treated lesions do not.

Randomized Trial of Cutting Balloon Compared With High-Pressure Angioplasty for the Treatment of Resistant Pulmonary Artery Stenosis

We sought to determine the safety and efficacy of Cutting Balloon therapy (CB) compared with conventional high-pressure balloon therapy (HPB) for the treatment of pulmonary artery stenosis. This prospective, randomized, multicenter, investigational device exemption trial compared CB with HPB. Patient eligibility was determined at the precatheterization assessment; vessel eligibility was determined at catheterization. In all vessels, low-pressure balloon dilation to 8 atm was performed, and if it was not successful, the vessel was randomized to CB or HPB. The primary efficacy outcome was percent change in minimum lumen diameter. A core laboratory performed all vessel measurements and angiographic assessment of vessel damage. The primary safety outcome was any serious adverse event attributable to vessel dilation as assessed by the Data and Safety Monitoring Board. Seventy-three patients from 8 institutions were enrolled between 2004 and 2008. In these patients, 72 vessels responded to low-pressure balloon dilation. Of the 173 vessels that met eligibility criteria, 107 were randomized to CB and 66 to HPB. In randomized vessels, CB therapy was associated with greater percent increase in lumen diameter (85% versus 52%; P=0.004). After crossover was introduced, 26 of 47 vessels treated with HPB underwent CB therapy and experienced an additional 48% increase in lumen diameter; the final diameter after CB was 99% greater than the initial diameter. There were no serious adverse events related to treatment in a study vessel. CB therapy for pulmonary artery stenosis not responsive to low-pressure balloon is more effective than HPB therapy and has an equivalent safety profile.

Reoperation After Supravalvular Aortic Stenosis Repair

Supravalvular aortic stenosis (SVAS) is the rarest type of left ventricular outflow tract obstruction. We reviewed our experience with this anomaly and analyzed risk factors for death or reoperation. Between 1984 and 2009, 49 patients had surgery for SVAS. A single-patch technique was used in 3, two-sinus enlargement in 39, and three-sinus enlargement in 7. Variables evaluated included age at surgery (<2 versus >2 years old), presence of pulmonary artery stenosis, type of SVAS (focal versus diffuse), presence of valvular aortic stenosis, and era of surgery. The only early death occurred in a patient who experienced cardiac arrest during anesthesia induction and could not be separated from bypass after surgery. There were 2 late deaths at 3 and 11 years after SVAS repair, both related to treatment for pulmonary artery stenosis. Actuarial survival at 5, 10, and 20 years was 95%, 95%, and 90%, respectively. Sixteen patients required 23 reoperations: for pulmonary artery stenosis (n = 10), distal aortic stenosis (n = 9), aortic valve stenosis (n = 4), and coronary artery stenosis (n = 1). Actuarial reoperation-free survivals at 5, 10, and 20 years were 73%, 58%, and 52%, respectively. Coexistent pulmonary artery stenosis, young age at surgery, and diffuse type SVAS were predictors of lower freedom from death or reoperation by both univariate and multivariate analyses. Survival after surgical repair of SVAS is excellent. However, reoperation is frequent, especially when the patients also have pulmonary artery stenosis, diffuse type SVAS, and initial surgery at a young age.

Cheatham-Platinum stent implantation for pulmonary artery stenosis in children and adolescents: immediate and mid-term outcome

NuMED Cheatham-Platinum (CP) stent implantation for pulmonary artery stenosis in children and adolescents has been rarely reported. This study aimed to evaluate the immediate and mid-term results of CP stent implantation for the treatment of pulmonary artery stenosis associated with congenital heart disease (CHD) in children and adolescents. From August 2005 to May 2007, four consecutive pediatric patients with pulmonary artery stenosis associated with CHD underwent CP stent implantation. They were followed up, and transthoracic echocardiography was done for outcome evaluation. In the four patients, 5 stent placement procedures were performed and 7 CP stents were implanted (8-zig, 22-39 mm in length). All stents except one were successfully placed in the target lesions without displacement during the procedures. After the procedure, the systolic pressure gradient across the stenosis decreased from 36.67 ± 20.08 to 3.67 ± 3.20 mmHg (P=0.005), and the narrowest diameter of the stenotic segment increased from 6.97 ± 2.22 to 13.40 ± 4.40 mm (P=0.013). Two stents implanted in the left and right pulmonary arteries in patient 4 developed intrastent restenosis 6 months after the procedure, and the distal end of the main pulmonary artery also developed restenosis 26 months later. The results of the remaining stents have been stable without complications during a median follow-up of 34 months (range, 26-48 months). Our experience indicates that CP stent implantation is suitable for the treatment of pulmonary artery stenosis in children and adolescents with CHD. The immediate and mid-term results are encouraging, but long-term results demand further follow-up in more cases.

Expanding indications for the treatment of pulmonary artery stenosis in children by using cutting balloon angioplasty

To evaluate the role of cutting balloon angioplasty in children with pulmonary artery stenosis. Pulmonary artery stenoses can be either congenital or secondary to postoperative scar formation. Isolated multiple small-vessel pulmonary artery stenoses are very rare. No surgical procedures for their treatment are currently available. We report on four patients in whom standard and high-pressure balloon angioplasty had failed. Three of the four (2.5-, 3-, and 3.5-years-old; two girls) had isolated multiple peripheral pulmonary artery stenosis. The fourth patient was an 11-month-old girl (8 kg) with tetralogy of Fallot and hypoplastic pulmonary artery branches treated with the implantation of two stents in the pulmonary arteries. During the follow-up this patient developed severe intrastent restenosis and showed severely hypoplasic distal left pulmonary artery. We treated 11 vessels. The mean vessel diameter increased by 81% (P<0.0001) and RV/LV pressure ratio decreased from 1.15 to 0.75 (P=0.05). Patient treated for intrastent restenosis underwent successful complete tetralogy of Fallot repair. None of the patients suffered procedure-related complications. At a median follow-up of 18 months, results were stable and no late complications had occurred. Cutting balloon angioplasty is a promising technique for the treatment of highly challenging pathologies such as small vessel pulmonary artery stenoses and intrastent restenosis.

Gadolinium‐based balloon angioplasty for pulmonary artery stenosis in an infant with a right isomerism

We report here the first described case of utilizing gadolinium-based contrast material as the contrast agent during a catheter intervention treatment for pulmonary artery stenosis. The patient, a male infant with complex heart disease associated with a right isomerism, had a history of severe allergic reaction to iodine-containing contrast agents. A combination of digital subtraction angiography and a gadolinium contrast agent, however, provided us with good-quality images both before and after balloon angioplasty without any associated complications. This method should therefore be considered as an alternative angiographic procedure in children with a high risk of iodine-related allergic complications.