Ann Thorac Surg 2002;73:1962-1964
© 2002 The Society of Thoracic Surgeons
Case report
Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy
Yuji Asato, MDa*,
Ryuta Amemiya, MDa,
Moriyuki Kiyoshima, MDa,
Yasukazu Shioyama, MDb,
Mikio Asato, MDc
a Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, Ibaraki, Japan
b Department of Radiology, Ibaraki Prefectural Central Hospital and Cancer Center, Ibaraki, Japan
c Department of Radiology, Miyazaki Medical College, Miyazaki, Japan
Accepted for publication December 4, 2001.
* Address reprint requests to Dr Yuji Asato, Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, Ibaraki 309-1793, Japan
e-mail: y-asato{at}chubyoin.pref.ibaraki.jp
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Abstract
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We present a case of a patient with stenosis of the pulmonary artery which was successfully treated by implantation of a vascular endoprosthesis. A 50-year-old man underwent left pneumonectomy for lung cancer. Eleven months later, a computed tomographic scan revealed a soft tissue mass in the mediastinum and there was severe stenosis of the remaining right main pulmonary artery. A self-expandable vascular endoprosthesis was implanted in the stenotic portion. We used percutaneous cardiopulmonary support (PCPS) during the procedure. We recommend the technique of pulmonary artery stenting using PCPS as efficacious and safe.
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Introduction
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Recently endovascular stent implants have been used in malignant obstructive lesions [1]. But there are few reports [2] of stenting for malignant stenosis of the pulmonary artery, although pulmonary artery stents have been successfully implanted for congenital anomalies [3] and anastomotic stenosis after lung transplantation [4]. We present a case of a patient with stenosis of the pulmonary artery due to recurrent lung cancer after left pneumonectomy that was successfully treated by implantation of a vascular endoprosthesis.
A 50-year-old man underwent left pneumonectomy for lung cancer. Eleven months later, he felt swelling of his face and left arm, and shortness of breath. A computed tomographic (CT) scan revealed a soft tissue mass in the mediastinum, an obstruction of the left innominate vein, and severe stenosis of the remaining right main pulmonary artery (Fig 1),
which had not been detected in a CT scan 3 months before. An echocardiogram showed a dilated right heart and severe tricuspid regurgitation. An abdominal echogram revealed ascites and dilation of the vena cava and hepatic vein. His performance status according to the Eastern Cooperative Oncology Group criteria was 3. We diagnosed heart failure due to stenosis of the pulmonary artery that was life threatening. Brain, abdominal CTs, and bone scintigraphy revealed no metastatic lesions. We recommended a stent implant to his right pulmonary artery. Informed consent was obtained. To reduce increasing right ventricular afterload during the procedure, we planned to use percutaneous cardiopulmonary support (PCPS).
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Fig 1. Three-dimensional computed tomography pulmonary angiography on admission. There is severe stenosis at the right main pulmonary artery.
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When we did the procedure, we first inserted the PCPS cannula under general anesthesia, performed pulmonary angiography, and measured pulmonary arterial pressure. Prestenotic and poststenotic pulmonary arterial pressures were 97/10 and 61/8 mm Hg, respectively, and cardiac output was 2.27 l/min (cardiac index 1.65). After starting PCPS at a flow of 2.5 l/min, we dilated the stenotic portion using a balloon to confirm the feasibility for implanting a vascular endoprosthesis; the artery was easily dilated. After injection of urokinase to prevent thrombosis, a self-expandable vascular endoprosthesis (Easy Wall stent, Boston Scientific, Natick, MA) with a diameter of 16 mm and a length of 45 mm was implanted. Just after implantation, the pulmonary arterial pressure gradient disappeared and the absolute value was 65/7 mm Hg. Cardiac output increased to 2.92 l/min (cardiac index 2.12). We stopped PCPS and finished the procedure. The patient’s status improved and his performance status increased to 2 from 3. CT examination 8 days after implantation showed a good opening of the stent (Fig 2).
He is alive with the tumor now, 5 months after implantation.
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Fig 2. Multiplanar reconstructed image after stent implantation. Pulmonary artery is well dilated by the wall stent.
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Comment
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We think that patients suffering from stenosis of the pulmonary artery due to malignancy are not rare. But candidates for stenting of malignant pulmonary stenosis are rare because these patients usually have another serious problem, such as tracheobronchial stenosis or distant metastases. Balkin and colleagues [2] reported a case of pulmonary artery stenting for malignant stenosis but that case died 8 weeks after stenting because of tumor overgrowth beyond the stent. In our case, the tumor did not protrude into the lumen of pulmonary artery and therefore was suitable for a wall stent. There was no tracheobronchial stenosis or systemic metastases. We considered this stenosis life threatening. This patient already had a left pneumonectomy, so there was the possibility of cardiac arrest during the procedure. To reduce this risk, we used PCPS, which was effective, and the procedure was carried out safely. Currently, many cases of stenting for malignant stenosis of the bronchial tree are reported [5]. Some of these cases also may suffer from pulmonary artery stenosis and may be candidates for arterial stenting. For increasing safety during the procedure, we recommend using PCPS, and accordingly, this procedure may become more widely accepted.
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References
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Schindler N., Vogelzang R.L. Superior vena cava syndrome: experience with endovascular stents and surgical therapy. Surg Clin North Am 1999;79:683-694.[Medline]
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Balkin P.W., Imoto E.M. Treatment of malignant obstruction of the right ventricular outflow tract and pulmonary artery with metallic stent. AJR Am J Roentgenol 1997;169:439-440.[Free Full Text]
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O’Laughlin M.P. Catheterization treatment of stenosis and hypoplasia of pulmonary arteries. Pediatr Cardiol 1998;19:48-56.[Medline]
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Gaubert J.Y., Thomas P., Gaubert M.R., Noirclerc M., Bartoli J. Anastomotic stenosis of the left pulmonary artery after lung transplantation: treatment by percutaneous placement of an endoprosthesis. AJR Am J Roentgenol 1993;161:947-949.[Free Full Text]
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Sawada S., Tanigawa N., Kobayashi M., Furui S., Ohta Y. Malignant trachiobronchial obstructive lesion: treatment with Gianturco expandable metallic stents. Radiology 1993;188:205-208.[Abstract/Free Full Text]
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Abstract
Introduction
