SESSION TITLE: Transplant Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 26, 2014 at 03:15 PM - 04:15 PM
INTRODUCTION: Perfusion mismatch in a post-operative lung transplant patient can be a treatment challenge if a pulmonary embolus is not evident. Our case illustrates the importance of considering alternative diagnoses.
CASE PRESENTATION: A 65 year old, never-smoking male with idiopathic pulmonary fibrosis listed for lung transplantation was admitted for worsening hypoxemia and a persistent left-sided pneumothorax despite talc pleurodesis and bullectomy. Following chest tube placement the air leak persisted. He underwent a single right orthotopic lung transplant to avoid transplantation into a hostile chest cavity. Post-operative course was complicated by persistent hypercarbia and continued left air leak; perfusion scan revealed minimal perfusion to the native lung and decreased perfusion to right apex. CTA was negative for pulmonary embolus; patient was on anticoagulation for PICC-related clot. Patient then underwent a left pneumonectomy yet remained hypercarbic. Repeat perfusion scan demonstrated a perfusion deficit in the right apex. CTA was negative for an embolus; review of the coronal cuts revealed a stricture at the origin of the right upper lobe artery correlating with decreased perfusion. Retrospectively, the stricture was visualized on coronal reconstruction images of the earlier CTA. Patient underwent stenting of the right upper lobe pulmonary artery with resolution of stenosis and markedly improved pulmonary perfusion; hypercarbia has improved.
DISCUSSION: Pulmonary vascular complications following lung transplant surgery represent a rare cause of a perfusion mismatch; arterial and venous stenosis has been reported. A retrospective study of 720 patients documented a 1.8% occurrence. Therefore, pulmonary vascular stenosis may not be entertained early in the evaluation of post-operative perfusion mismatch especially when not evident on cross-sectional CT cuts.
CONCLUSIONS: Our case highlights the importance of considering pulmonary vascular stenosis in evaluation of perfusion mismatch/unexpected dead space in a recently transplanted lung and utilizing coronal CT images for early detection. Although surgery is the preferred treatment of post-transplant pulmonary artery stenosis, endovascular stenting may provide an alternative when operative risks are high or when only a subsegment of a pulmonary artery is involved as in our case.
Reference #1: Siddique A. Vascular anastomotic complications in lung transplantation. Interact Cardiovasc Thorac Surg. 2013;17(4):625-31.
DISCLOSURE: The following authors have nothing to disclose: Jonathan Danaraj, Lioudmila Karnatovskaia, Cesar Keller
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