Stenting of Single Remaining Pulmonary Artery Velchev v. , Stoyanov N., nedevska m. ivanchev k.

Just another ph patient? Medical History Just another ph patient? 56-years-old male referred for PH workup Fatigue and exertion dyspnea III FC (WHO) started two months ago Echocardiography – estimated systolic pressure of 100 mmHg, TAPSE 13 mm, Tricuspid regurgitation III-IV Left Pneumonectomy - two years ago( Lung cancer) f/o radiation and chemotherapy; FU CT 3 mo ago red as “unremarkable” comparing to postop

CT angiography RUPV

First Stage - stenting of the pulmonary artery Treatment plan multidisciplinary team (oncologist, invasive cardiologist and radiologist) decision making First Stage - stenting of the pulmonary artery Second Stage- chemotherapy

Literature – not really helpful Treatment plan How to do it? Literature – not really helpful Call an experienced friend (prof. K.Ivanchev) – Good support – amplatz wire Use the selfexpandable stent of suficient size that you know best to stent to the lower lobe branch Be prepared with balloon expandable stent in case of malexpansion (PS bare)

Right catheterization SPAP 10 mmHg SPAP 91 mmHg Gradient through the stenosis-81 mmHg

Procedure Planning Right femoral vein - Cook 12 F introducer It’s simple isn’t it? Right femoral vein - Cook 12 F introducer Stenosis crossing with pig tail catheter Amplatz super stiff guidewire Wallstent 20/40 mm Postdilatation

Wallstent 20/40 mm

Wallstent 20/40 mm

Postdilatation 20/16

During postdilatation !!! Blood pressure Unconsciousness Inotrope support - Adrenalin, Dopamine

Final result

Fluorography of stent expansion ten days after the procedure. SPAP – 60mmHg II FC (WHO) Marked reduction of dyspnea Late stent dilatation up to 10 mm

6 Months Follow Up Clinical Return of symptoms of dyspnea on exertion - WHO Class II -III Echocardiography: Estimated systolic pulmonary arterial pressure - 65 mmHg Marked weight loss The patient just finished his third chemotherapy course.

CT-angiograph – encasement of patent RPA, continuing stent expansion 6 Months Follow Up CT-angiograph – encasement of patent RPA, continuing stent expansion

CT- angiography- Disease progression 6 Months Follow Up CT- angiography- Disease progression RUPV compression Ground glass appearance of dependent lung parenchyma

RUPV stenting with transseptal approach

Risk/benefit ratio is difficult to calculate in desperate situation What do we learn? Treating malignant compression you need to be prepared for issue of stent malexpansion Risk/benefit ratio is difficult to calculate in desperate situation Treating big vessel malignant compression can gain quality and quantity of life and