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Percutaneous stenting of pulmonary artery stenosis secondary to malignant mediastinal adenopathy—A report of two cases
European Journal of Radiology Extra 71 (2009) e11–e13
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Percutaneous stenting of pulmonary artery stenosis secondary to malignant mediastinal adenopathy—A report of two cases Gareth Bydawell ∗ , Graham Munneke, Anna-Maria Belli Department of Radiology, St George’s Hospital, London SW17 0QT, United Kingdom
a r t i c l e
i n f o
Article history: Received 26 November 2008 Accepted 8 January 2009 Keywords: Pulmonary artery Stenting Mediastinal lymphadenopathy
a b s t r a c t Malignant compression of the main pulmonary arteries is associated with considerable patient morbidity including dyspnoea and reduced exercise tolerance. Endovascular stenting of the affected artery is a relatively rare technique with few reported cases in medical literature. We present two cases of percutaneous stenting of the pulmonary artery, along with a review of the technique and its limitations. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Stenting of the pulmonary artery is an uncommonly performed procedure with most data arising in the paediatric setting of congenital pulmonary artery stenosis [1,2]. This technique has also been reported for patients with fibrosing mediastinitis [3–6], pulmonary emboli [7], mycotic aneurysm [8] and rare conditions such as William syndrome [9]. In terms of mediastinal malignancy there are only 6 other case reports of successful stenting for both primary neoplastic disease and mediastinal adenopathy [10–15]. Stenting is usually performed for unilateral stenosis but bilateral stent insertion has been described with good clinical outcome [13]. It is widely accepted clinical practice to stent the significantly stenosed SVC in the setting of mediastinal malignancy. This is indicated when the patient presents with clinical features of SVC obstruction. On the other hand the clinical manifestations of pulmonary artery compression are less easily recognized and, as a result, not commonly treated. Also, in the dyspnoeic patient, there are often additional pathologies present such as pleural effusion, bronchial stenosis and lung metastases. Therefore it can be difficult assessing which abnormality to target for therapy. 2. Case report 2.1. Case 1 A 45-year-old man with metastatic malignant melanoma was referred for pulmonary artery stenting. He was diagnosed with
∗ Corresponding author. Tel.: +44 208 725 1160; fax: +44 208 725 2936. E-mail address: [email protected] (G. Bydawell). 1571-4675/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2009.01.003
malignant melanoma in 2000 and, following initial control of the disease, relapsed with lung and brain metastases in 2006. He underwent right upper lobectomy, and radiofrequency ablation to three deposits in the left lung, but unfortunately new mediastinal adenopathy was diagnosed on his next staging CT—this was causing severe compression of the right pulmonary artery (Fig. 1a) and mild SVC stenosis. Clinically he was suffering from progressive dyspnoea and the decision was made to proceed to pulmonary artery stenting in an attempt to improve his symptoms. A 4F pigtail catheter was inserted into the main pulmonary artery via the right common femoral vein. Angiography confirmed a tight occlusion of the right main pulmonary artery (Fig. 2a). A long 7F sheath was advanced into the proximal right pulmonary artery over a super stiff wire. The stenosis was crossed with a hydrophilic wire, and two self-expanding vascular stents (Luminexx, C.R. Bard, Murray Hill, NJ, USA) were deployed across the stenosis. Completion angiography showed patency of the proximal pulmonary artery with improved flow into the right middle and lower lobe arteries (Fig. 2b). The patient gained almost immediate symptomatic relief from the procedure and there were no complications from the procedure. On his subsequent 6-month follow-up CT his malignant disease had progressed however the right pulmonary artery was still well perfused (Fig. 1b).
2.2. Case 2 A 55-year-old man was referred for right pulmonary artery stenting because of progressive dyspnoea due to extrinsic compression from mediastinal adenopathy. He had a history of right lower lobectomy for lung carcinoid in 1990; liver metastases were
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G. Bydawell et al. / European Journal of Radiology Extra 71 (2009) e11–e13
Fig. 1. Severe compression of the right main pulmonary artery secondary to mediastinal adenopathy (a). Following pulmonary artery stenting (b) there has been good expansion of the vessel lumen with improved blood flow into the peripheral vessels.
diagnosed in 1997, and he had been treated with chemotherapy on several occasions for recurrent disease. Since December 2005 his disease status had remained stable but a CT scan dated February 2007 revealed progressive disease in the chest with mediastinal adenopathy causing compression of his right middle lobe pulmonary artery (Fig. 3). Given his concomitant respiratory deterioration the decision was taken to proceed with endovascular treatment. A 4 french pigtail catheter was placed into the main pulmonary artery via a right common femoral venous puncture and a tight stenosis of the right middle lobe pulmonary artery was confirmed (Fig. 4a). Due to an unstable catheter position in the right main pulmonary artery, venous access was switched to the right internal jugular vein. A long 7 french sheath was placed in the right main pulmonary artery and the stenotic middle lobe artery was traversed with hydrophilic wire and stented with an 8 mm × 30 mm self-expanding stent (Luminexx, C.R. Bard, Murray Hill, NJ, USA). A self-expanding stent was considered most appropriate to accommodate the difference in arterial lumen as the artery reduces in diameter distally. The post-procedure pulmonary angiogram confirmed improved arterial flow into the right middle lobe (Fig. 4b). There were no complications and the patient experienced prompt clinical improvement.
Fig. 2. Pulmonary arteriography (a) confirms tight occlusion of the right main pulmonary artery with normal appearances of the left pulmonary circulation. Following the placement of two self-expanding stents (b) there is improved flow into the right pulmonary artery.
Pulmonary artery stenosis in the oncological patient is seen secondary to primary lung malignancy or mediastinal adenopathy. From the 6 case reports of stenting for malignant pulmonary artery compression five patients had primary lung cancer, with the remaining case describing primary leiomyosarcoma of the pul-
3. Discussion Compression of the main pulmonary arteries is seen in various clinical settings but is an uncommonly treated condition. Limited experience in the procedure and failure to correlate symptoms with radiological findings are the two main reasons why the procedure is underperformed.
Fig. 3. Ill-defined soft tissue in the right hilar/mediastinal region, in keeping with carcinoid recurrence, is seen to compress the right middle lobe pulmonary artery.
G. Bydawell et al. / European Journal of Radiology Extra 71 (2009) e11–e13
e13
ever, a long vascular sheath is required for safer deployment of the stent once the stenosis has been traversed. Stent diameter is variable depending on the site of the stenosis. Central stenoses in the main right or left pulmonary arteries are simpler to deal with as the artery is reasonably uniform in calibre. The more distal stenosis requires a stent which can accommodate the caliber change from the main artery as it divides into branches, as in Case 2. A selfexpanding stent is therefore required in this type of situation, whilst it would be feasible to use a balloon expanding or self-expanding stent in the main artery. Complications of the procedure are rare but include: cardiac arrhythmia, arterial damage (dissection or rupture), distal embolization, stent misplacement, stent migration and transient pulmonary oedema [10,13]. 4. Conclusion In summary, with improved cross-sectional imaging in cancer staging, pulmonary arterial compression due to malignancy is likely to be diagnosed increasingly. Clinicians should be aware of the feasibility of stenting in these situations if clinical assessment suggests this to be the cause of dyspnoea and refer such cases for prompt treatment. The procedure is not without risk therefore this needs to be weighed up against the patient’s clinical staging and prognosis. However with careful technique this procedure can provide excellent symptomatic relief and palliation for patients with advanced cases of malignant pulmonary artery stenosis. References
Fig. 4. Diagnostic pulmonary arteriography (a) confirms significant stenosis of the right middle lobe pulmonary artery (black arrow) with pre-stenotic dilatation of the pulmonary trunk. A single self-expanding stent was deployed across the pulmonary artery stenosis with good angiographic result (b).
monary artery. In our report the pulmonary artery compression is secondary to mediastinal adenopathy from malignant melanoma and carcinoid, respectively. Other causes of acquired pulmonary stenosis include fibrosing mediastinitis, vascular compression (e.g. aortic aneurysm) and pulmonary emboli. The main symptoms include dyspnoea, fatigue on exertion and palpitations, and there may be underlying pulmonary hypertension. In advanced cases the patient may exhibit signs of right heart failure. Indications for pulmonary arterial stenting secondary to malignancy are not always clear cut and involve a thorough assessment of the patient’s disease status and prognosis, along with adequate cross-sectional imaging of the mediastinum to determine feasibility of the procedure. If necessary right heart catheterization and pulmonary angiography can be undertaken beforehand to confirm the diagnosis however the procedure is best performed as one complete episode where the possibility of proceeding to subsequent stenting is available. Venous access may be achieved by either a femoral or jugular route and this will depend on local preference and anatomy. How-
[1] Gatzoulis MA, Rigby ML, Redington AN. Interventional catheterization in paediatric cardiology. Eur Heart J 1995;16(12):1767–72. [2] O’Laughlin MP, Perry SB, Lock JE, et al. Use of endovascular stents in congenital heart disease. Circulation 1991;83(6):1923–39. [3] Doyle TP, Loyd JE, Robbins IM. Percutaneous pulmonary artery and vein stenting: a novel treatment for mediastinal fibrosis. Am J Respir Crit Care Med 2001;164(4):657–60. [4] Fontaine AB, Borsa JJ, Hoffer EK, et al. Stent placement in the treatment of pulmonary artery stenosis secondary to fibrosing mediastinitis. J Vasc Interv Radiol 2001;12(9):1107–11. [5] Guerrero A, Hoffer EK, Hudson L, et al. Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement. Chest 2001;119(3):966–8. [6] Kandzari DE, Warner JJ, O’Laughlin MP, et al. Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis. Catheter Cardiovasc Interv 2000;49(3):321–4. [7] Koizumi J, Kusano S, Akima T, et al. Emergent Z stent placement for treatment of cor pulmonale due to pulmonary emboli after failed lytic treatment: technical considerations. Cardiovasc Intervent Radiol 1998;21(3):254–5. [8] Chou MC, Liang HL, Pan HB, et al. Percutaneous stent-graft repair of a mycotic pulmonary artery pseudoaneurysm. Cardiovasc Intervent Radiol 2006;29(5): 890–2. [9] Reesink HJ, Henneman OD, Van Delden OM, et al. Pulmonary arterial stent implantation in an adult with Williams syndrome. Cardiovasc Intervent Radiol 2007;30(4):782–5. [10] Muller-Hulsbeck S, Bewig B, Schwarzenberg H, et al. Percutaneous placement of a self-expandable stent for treatment of a malignant pulmonary artery stenosis. Br J Radiol 1998;71(847):785–7. [11] Hirota S, Matsumoto S, Yoshikawa T, et al. Stent placement for malignant pulmonary artery structure. Cardiovasc Intervent Radiol 2000;23(3):242–4. [12] AsatoY, Amemiya R, Kiyoshima M, et al. Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy. Ann Thorac Surg 2002;73(6): 1962–4. [13] Fierro-Renoy C, Velasquez H, Zambrano JP, et al. Percutaneous stenting of bilateral pulmonary artery stenosis caused by malignant extrinsic compression. Chest 2002;122(4):1478–80. [14] Meckel S, Buitrago-Tellez C, Herrmann R, et al. Stenting for pulmonary artery stenosis due to a recurrent primary leiomyosarcoma. J Endovasc Ther 2003;10(1):141–6. [15] Gutzeit A, Koch S, Meier UR, et al. Stent implantation for malignant pulmonary artery stenosis in a metastasizing non-small cell bronchial carcinoma. Cardiovasc Intervent Radiol 2008;31(Suppl 2):S149–52.
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Percutaneous stenting of pulmonary artery stenosis secondary to malignant mediastinal adenopathy—A report of two cases Gareth Bydawell ∗ , Graham Munneke, Anna-Maria Belli Department of Radiology, St George’s Hospital, London SW17 0QT, United Kingdom
a r t i c l e
i n f o
Article history: Received 26 November 2008 Accepted 8 January 2009 Keywords: Pulmonary artery Stenting Mediastinal lymphadenopathy
a b s t r a c t Malignant compression of the main pulmonary arteries is associated with considerable patient morbidity including dyspnoea and reduced exercise tolerance. Endovascular stenting of the affected artery is a relatively rare technique with few reported cases in medical literature. We present two cases of percutaneous stenting of the pulmonary artery, along with a review of the technique and its limitations. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Stenting of the pulmonary artery is an uncommonly performed procedure with most data arising in the paediatric setting of congenital pulmonary artery stenosis [1,2]. This technique has also been reported for patients with fibrosing mediastinitis [3–6], pulmonary emboli [7], mycotic aneurysm [8] and rare conditions such as William syndrome [9]. In terms of mediastinal malignancy there are only 6 other case reports of successful stenting for both primary neoplastic disease and mediastinal adenopathy [10–15]. Stenting is usually performed for unilateral stenosis but bilateral stent insertion has been described with good clinical outcome [13]. It is widely accepted clinical practice to stent the significantly stenosed SVC in the setting of mediastinal malignancy. This is indicated when the patient presents with clinical features of SVC obstruction. On the other hand the clinical manifestations of pulmonary artery compression are less easily recognized and, as a result, not commonly treated. Also, in the dyspnoeic patient, there are often additional pathologies present such as pleural effusion, bronchial stenosis and lung metastases. Therefore it can be difficult assessing which abnormality to target for therapy. 2. Case report 2.1. Case 1 A 45-year-old man with metastatic malignant melanoma was referred for pulmonary artery stenting. He was diagnosed with
∗ Corresponding author. Tel.: +44 208 725 1160; fax: +44 208 725 2936. E-mail address: [email protected] (G. Bydawell). 1571-4675/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2009.01.003
malignant melanoma in 2000 and, following initial control of the disease, relapsed with lung and brain metastases in 2006. He underwent right upper lobectomy, and radiofrequency ablation to three deposits in the left lung, but unfortunately new mediastinal adenopathy was diagnosed on his next staging CT—this was causing severe compression of the right pulmonary artery (Fig. 1a) and mild SVC stenosis. Clinically he was suffering from progressive dyspnoea and the decision was made to proceed to pulmonary artery stenting in an attempt to improve his symptoms. A 4F pigtail catheter was inserted into the main pulmonary artery via the right common femoral vein. Angiography confirmed a tight occlusion of the right main pulmonary artery (Fig. 2a). A long 7F sheath was advanced into the proximal right pulmonary artery over a super stiff wire. The stenosis was crossed with a hydrophilic wire, and two self-expanding vascular stents (Luminexx, C.R. Bard, Murray Hill, NJ, USA) were deployed across the stenosis. Completion angiography showed patency of the proximal pulmonary artery with improved flow into the right middle and lower lobe arteries (Fig. 2b). The patient gained almost immediate symptomatic relief from the procedure and there were no complications from the procedure. On his subsequent 6-month follow-up CT his malignant disease had progressed however the right pulmonary artery was still well perfused (Fig. 1b).
2.2. Case 2 A 55-year-old man was referred for right pulmonary artery stenting because of progressive dyspnoea due to extrinsic compression from mediastinal adenopathy. He had a history of right lower lobectomy for lung carcinoid in 1990; liver metastases were
e12
G. Bydawell et al. / European Journal of Radiology Extra 71 (2009) e11–e13
Fig. 1. Severe compression of the right main pulmonary artery secondary to mediastinal adenopathy (a). Following pulmonary artery stenting (b) there has been good expansion of the vessel lumen with improved blood flow into the peripheral vessels.
diagnosed in 1997, and he had been treated with chemotherapy on several occasions for recurrent disease. Since December 2005 his disease status had remained stable but a CT scan dated February 2007 revealed progressive disease in the chest with mediastinal adenopathy causing compression of his right middle lobe pulmonary artery (Fig. 3). Given his concomitant respiratory deterioration the decision was taken to proceed with endovascular treatment. A 4 french pigtail catheter was placed into the main pulmonary artery via a right common femoral venous puncture and a tight stenosis of the right middle lobe pulmonary artery was confirmed (Fig. 4a). Due to an unstable catheter position in the right main pulmonary artery, venous access was switched to the right internal jugular vein. A long 7 french sheath was placed in the right main pulmonary artery and the stenotic middle lobe artery was traversed with hydrophilic wire and stented with an 8 mm × 30 mm self-expanding stent (Luminexx, C.R. Bard, Murray Hill, NJ, USA). A self-expanding stent was considered most appropriate to accommodate the difference in arterial lumen as the artery reduces in diameter distally. The post-procedure pulmonary angiogram confirmed improved arterial flow into the right middle lobe (Fig. 4b). There were no complications and the patient experienced prompt clinical improvement.
Fig. 2. Pulmonary arteriography (a) confirms tight occlusion of the right main pulmonary artery with normal appearances of the left pulmonary circulation. Following the placement of two self-expanding stents (b) there is improved flow into the right pulmonary artery.
Pulmonary artery stenosis in the oncological patient is seen secondary to primary lung malignancy or mediastinal adenopathy. From the 6 case reports of stenting for malignant pulmonary artery compression five patients had primary lung cancer, with the remaining case describing primary leiomyosarcoma of the pul-
3. Discussion Compression of the main pulmonary arteries is seen in various clinical settings but is an uncommonly treated condition. Limited experience in the procedure and failure to correlate symptoms with radiological findings are the two main reasons why the procedure is underperformed.
Fig. 3. Ill-defined soft tissue in the right hilar/mediastinal region, in keeping with carcinoid recurrence, is seen to compress the right middle lobe pulmonary artery.
G. Bydawell et al. / European Journal of Radiology Extra 71 (2009) e11–e13
e13
ever, a long vascular sheath is required for safer deployment of the stent once the stenosis has been traversed. Stent diameter is variable depending on the site of the stenosis. Central stenoses in the main right or left pulmonary arteries are simpler to deal with as the artery is reasonably uniform in calibre. The more distal stenosis requires a stent which can accommodate the caliber change from the main artery as it divides into branches, as in Case 2. A selfexpanding stent is therefore required in this type of situation, whilst it would be feasible to use a balloon expanding or self-expanding stent in the main artery. Complications of the procedure are rare but include: cardiac arrhythmia, arterial damage (dissection or rupture), distal embolization, stent misplacement, stent migration and transient pulmonary oedema [10,13]. 4. Conclusion In summary, with improved cross-sectional imaging in cancer staging, pulmonary arterial compression due to malignancy is likely to be diagnosed increasingly. Clinicians should be aware of the feasibility of stenting in these situations if clinical assessment suggests this to be the cause of dyspnoea and refer such cases for prompt treatment. The procedure is not without risk therefore this needs to be weighed up against the patient’s clinical staging and prognosis. However with careful technique this procedure can provide excellent symptomatic relief and palliation for patients with advanced cases of malignant pulmonary artery stenosis. References
Fig. 4. Diagnostic pulmonary arteriography (a) confirms significant stenosis of the right middle lobe pulmonary artery (black arrow) with pre-stenotic dilatation of the pulmonary trunk. A single self-expanding stent was deployed across the pulmonary artery stenosis with good angiographic result (b).
monary artery. In our report the pulmonary artery compression is secondary to mediastinal adenopathy from malignant melanoma and carcinoid, respectively. Other causes of acquired pulmonary stenosis include fibrosing mediastinitis, vascular compression (e.g. aortic aneurysm) and pulmonary emboli. The main symptoms include dyspnoea, fatigue on exertion and palpitations, and there may be underlying pulmonary hypertension. In advanced cases the patient may exhibit signs of right heart failure. Indications for pulmonary arterial stenting secondary to malignancy are not always clear cut and involve a thorough assessment of the patient’s disease status and prognosis, along with adequate cross-sectional imaging of the mediastinum to determine feasibility of the procedure. If necessary right heart catheterization and pulmonary angiography can be undertaken beforehand to confirm the diagnosis however the procedure is best performed as one complete episode where the possibility of proceeding to subsequent stenting is available. Venous access may be achieved by either a femoral or jugular route and this will depend on local preference and anatomy. How-
[1] Gatzoulis MA, Rigby ML, Redington AN. Interventional catheterization in paediatric cardiology. Eur Heart J 1995;16(12):1767–72. [2] O’Laughlin MP, Perry SB, Lock JE, et al. Use of endovascular stents in congenital heart disease. Circulation 1991;83(6):1923–39. [3] Doyle TP, Loyd JE, Robbins IM. Percutaneous pulmonary artery and vein stenting: a novel treatment for mediastinal fibrosis. Am J Respir Crit Care Med 2001;164(4):657–60. [4] Fontaine AB, Borsa JJ, Hoffer EK, et al. Stent placement in the treatment of pulmonary artery stenosis secondary to fibrosing mediastinitis. J Vasc Interv Radiol 2001;12(9):1107–11. [5] Guerrero A, Hoffer EK, Hudson L, et al. Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement. Chest 2001;119(3):966–8. [6] Kandzari DE, Warner JJ, O’Laughlin MP, et al. Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis. Catheter Cardiovasc Interv 2000;49(3):321–4. [7] Koizumi J, Kusano S, Akima T, et al. Emergent Z stent placement for treatment of cor pulmonale due to pulmonary emboli after failed lytic treatment: technical considerations. Cardiovasc Intervent Radiol 1998;21(3):254–5. [8] Chou MC, Liang HL, Pan HB, et al. Percutaneous stent-graft repair of a mycotic pulmonary artery pseudoaneurysm. Cardiovasc Intervent Radiol 2006;29(5): 890–2. [9] Reesink HJ, Henneman OD, Van Delden OM, et al. Pulmonary arterial stent implantation in an adult with Williams syndrome. Cardiovasc Intervent Radiol 2007;30(4):782–5. [10] Muller-Hulsbeck S, Bewig B, Schwarzenberg H, et al. Percutaneous placement of a self-expandable stent for treatment of a malignant pulmonary artery stenosis. Br J Radiol 1998;71(847):785–7. [11] Hirota S, Matsumoto S, Yoshikawa T, et al. Stent placement for malignant pulmonary artery structure. Cardiovasc Intervent Radiol 2000;23(3):242–4. [12] AsatoY, Amemiya R, Kiyoshima M, et al. Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy. Ann Thorac Surg 2002;73(6): 1962–4. [13] Fierro-Renoy C, Velasquez H, Zambrano JP, et al. Percutaneous stenting of bilateral pulmonary artery stenosis caused by malignant extrinsic compression. Chest 2002;122(4):1478–80. [14] Meckel S, Buitrago-Tellez C, Herrmann R, et al. Stenting for pulmonary artery stenosis due to a recurrent primary leiomyosarcoma. J Endovasc Ther 2003;10(1):141–6. [15] Gutzeit A, Koch S, Meier UR, et al. Stent implantation for malignant pulmonary artery stenosis in a metastasizing non-small cell bronchial carcinoma. Cardiovasc Intervent Radiol 2008;31(Suppl 2):S149–52.