Stenting for Peripheral Pulmonary Artery Stenosis after Total Surgical Correction of TOF

- Operator : Seung-Jung Park

Stenting for Peripheral Pulmonary Artery Stenosis after Total Surgical Correction of TOF

- Operator: Seung-Jung Park, MD, PhD, Korea

Case Presentation

A 24-year old male presented in right side heart failure. At age 2 years, he underwent total surgical correction of Tetralogy of Fallot (TOF) and left pulmonary artery repair in Australia. The patient remained well for many years. At age 17 years, he was recognized to have left pulmonary artery stenosis. Therefore, stent implantation was performed for left pulmonary artery stenosis in a US hospital. However, in-stent restenosis was developed. Repeated balloon angioplasty were also not successful for treatment of in-stent restenosis. Finally he was transferred to this hospital with severe right heart failure. Echocardiogram showed dilated right ventricle and D-shaped left ventricle implying right ventricular pressure overloading.(Figure 1) Estimated systolic pulmonary arterial pressure from tricuspid regurgitation was 73mmHg. There was no remnant shunt at the operation sites. The heart MRI showed total occlusion of left pulmonary artery and focal stenosis at the middle portion of right pulmonary artery.(Figure 2) We planed to treat the right pulmonary artery stenosis with percutaneous approach for relieving right ventricular pressure because the stented portion of left pulmonary artery was totally occluded.

Procedure

After inserting a 12 Fr sheath through right femoral vein, Pig-tail catheter was advanced into the right pulmonary artery (RPA). Right pulmonary angiogram showed a critical stenosis at the proximal segment of RPA (Figure 3). The main pulmonary systolic and mean arterial pressures were 70mmHg and 39mmHg, respectively. The distal RPA systolic and mean arterial pressures were 55mmHg and 36mmHg, respectively. Because of the morphological stenosis and pressure step-up, we intended to treat the lesion with stenting. After advancement of 11 Fr Mullin sheath into the RPA,(Figure 4) a 16x40mm Wall stent (Wall stent UNI, Boston Scientific) was positioned to cover the lesion.(Figure 5) Angiogram after stent deployment showed residual indentation in the middle portion of the stent.(Figure 6) Therefore, additional balloon dilatation was performed with a 18x20mm (XXL balloon, Boston Scientific) balloon (Figure 7). Final angiogram showed a very good result.(Figure 8) The main pulmonary systolic and mean arterial pressures were decreased to 41mmHg and 29mmHg, respectively.