Name: Catheter-based Endovascular Angioplasty for Fibrosing Mediastinitis-associated Pulmonary Vein Stenosis (Video) | JoVE Journal
Uploaded: 2025-08-26T13:00:00.000+00:00
Duration: 6 min 59 s
Description: Learn catheter-based endovascular angioplasty for fibrosing mediastinitis-associated pulmonary vein stenosis. This method demonstrates re-stenting techniques and transseptal catheterization procedures for improved patient outcomes.

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5 minutes

The procedures involving human subjects were approved by the ethics committee of Sichuan Provincial People&#39;s Hospital. Patient consent was obtained to include anonymized data for the protocol and video publication. The inclusion criterion was patients who were diagnosed with PVS-FM through CTPA, met the indications for interventional therapy, and were scheduled to undergo PV intervention. The exclusion criteria were as follows: patients with end-stage disease, active bleeding, expected intolerance to long-term antithrombotic therapy, or allergies to contrast agents. Details of the reagents and equipment used in this study are listed in the Table of Materials.
1. CTPA evaluation
NOTE: CTPA assessment is crucial for establishing an accurate diagnosis and formulating an effective intervention strategy for patients.
<ol>
	<li>Evaluate the lung parenchyma, trachea, bronchi, pulmonary vessels, and heart using CTPA prior to the interventional procedure.</li>
	<li>Examine the CTPA images (Figure 1A) to identify proliferative fibrous tissues in the pulmonary hila, compressing the pulmonary veins, pulmonary arteries, and bronchi, resulting in stenoses of the pulmonary vessels, which indicate the mixed FM.</li>
	<li>Observe the 3-D VR image (Figure 1B) to assess the severe stenoses in the left superior pulmonary vein (LSPV) and the right superior pulmonary vein (RSPV).</li>
</ol>
2. Monitoring vital signs and preparing sterile equipment
<ol>
	<li>Assist the patient in lying down on his back, connect the monitoring equipment, and record the ECG, heart rate, peripheral oxygen saturation, and blood pressure.</li>
	<li>Establish a peripheral venous access line and connect it to 500 mL of normal saline.</li>
	<li>Prepare rescue medications, including adrenaline, norepinephrine, atropine, dopamine, lidocaine, nitroglycerin, and vasopressin, as well as rescue equipment such as the tracheal intubation kit, pericardiocentesis kit, and defibrillator device. Ensure cardiovascular ultrasound is available for procedural assistance if needed.</li>
	<li>Prepare sterile equipment with the materials required by the catheter assistant or nurse. 
	NOTE: The main equipment needed includes the Judkins Right/Left (JR/JL) Guiding Catheter, Transseptal Guiding Introducer, Transseptal Needle, Catheter Sheath Introducer, Balloon Dilatation Catheter, Vascular Premounted Stent System, Guide Wire, and Everest Inflation Device.</li>
	<li>Flush all the catheters with heparinized saline to prevent thromboembolic complications.</li>
</ol>
3. Establishing femoral vein access and performing selective right pulmonary artery angiography
NOTE: In patients with pulmonary vein stenosis (PVS), left atrial atrophy may increase the risk of procedural complications. To enhance the identification of adjacent anatomical structures and mitigate these risks, routine angiography of the right inferior pulmonary artery (RIPA) is typically performed. In cases where the RIPA is occluded, angiography of the right superior pulmonary artery (RSPA) may serve as an alternative approach, as exemplified by the case described in this study.
<ol>
	<li>Sterilize the right groin using a povidone-iodine solution. Administer 3-5 mL of lidocaine subcutaneously above the puncture site in the groin. Access the right femoral vein using palpation or ultrasound guidance.</li>
	<li>Insert an 8 French catheter sheath into the right femoral vein.</li>
	<li>Insert a 0.035-inch guidewire and deliver the guiding catheter to the RSPA through femoral vein access via the guidewire.</li>
	<li>Withdraw the guidewire and perform selective RSPA angiography to establish the location of the left atrium in the 45&#176; right anterior oblique (RAO) view. Observe the initial site of contrast agent arrival at the RSPA, followed by the right superior&#160;pulmonary vein (RSPV), left atrium, left ventricle, and ascending aorta.</li>
	<li>Pull out the JR guiding catheter.</li>
</ol>
4. Transseptal procedure
<ol>
	<li>Insert a 0.032-inch &#34;J&#34; tip guidewire into the superior vena cava (SVC) and remove the 8 French catheter sheath.</li>
	<li>Advance the transseptal guiding sheath/dilator assembly into the SVC over the &#34;J&#34; tip guidewire under anterior-posterior (AP) fluoroscopy.</li>
	<li>Remove the guidewire from the dilator.</li>
	<li>Position the transseptal needle and stylet assembly until the stylet is positioned just proximal to the dilator tip inside the sheath.</li>
	<li>Remove the stylet.</li>
	<li>Adjust the pointer flange so that the needle is positioned perpendicular to the fossa ovalis in the anteroposterior (AP) view, typically between 3:00 and 5:00 o&#39;clock, as seen from the foot end of the patient.</li>
	<li>Verify that the needle tip is within the dilator using fluoroscopy. Gradually retract the entire sheath/dilator/needle assembly. Monitor the dilator tip for any sudden medial (or rightward) movement during retraction, which would indicate engagement with the fossa ovalis. 
	NOTE: Ensure that the assembly parts remain stationary relative to each other. Maintain the initial orientation of the pointer flange while retracting the assembly.</li>
	<li>Visualize and identify anatomic landmarks in the 45&#176; RAO view.</li>
	<li>Extend the needle to full engagement within the sheath/dilator assembly and advance it across the interatrial septum. Ensure the blood is arterial blood. 
	NOTE: If resistance is encountered during needle advancement, retract the needle and reassess the anatomical landmarks. In the event of pericardial or aortic entry, do not advance the dilator over the needle. If the needle has punctured the pericardium or aorta, withdraw it immediately. Continuously monitor vital signs.</li>
	<li>Confirm left atrial access via fluoroscopy with contrast injections. 
	NOTE: Under pressure monitoring, confirm left atrial entry when the pressure tracing shows a left atrial pressure waveform.</li>
	<li>Maintain a fixed needle position within the left atrium and advance the sheath/dilator assembly fully over the needle into the left atrial cavity.</li>
	<li>Remove the transseptal needle from the dilator. 
	NOTE: Air infiltration may occur when removing objects from the hemostasis valve of the sheath. Withdraw objects gradually to avoid vacuum formation in the sheath and monitor the sheath fluoroscopically for the presence of air during device insertion.</li>
	<li>Insert the 0.035-inch guidewire and advance it into the LSPV.</li>
	<li>Advance the sheath fully into the left atrial cavity over the dilator, and then withdraw it.</li>
	<li>Insert the guiding catheter and advance it into the left atrium over the guidewire. Withdraw the guidewire.</li>
	<li>Measure the left atrial pressure via the guiding catheter.</li>
</ol>
5. Selective pulmonary venography
NOTE: Maintain the activated clotting time within an appropriate range of 250-350 s to avoid thromboembolic complications.
<ol>
	<li>Advance a 0.014-inch Runthrough guidewire into the distal LSPV.</li>
	<li>Gently pass the guiding catheter over the wire, positioning its tip at the distal part of the stenosis.</li>
	<li>Monitor changes in pressure. An increase in pressure compared to the left atrial pressure indicates that the guiding catheter is either at or has passed through the narrow lesion.</li>
	<li>Perform selective pulmonary venography to accurately evaluate the lesion&#39;s location, the severity of stenosis, and the grade of pulmonary vein flow.</li>
	<li>Record pressure measurements of the distal part of the stenosis.</li>
	<li>Retract the JR guiding catheter to the proximal part to measure the proximal pressure and calculate the pressure gradient (PG) across the lesion.</li>
</ol>
6. Balloon angioplasty and stent implantation for pulmonary veins
NOTE: Confirm the guidewire position under venography to prevent vessel dissection, perforation, or unintended pericardial entry.&#160;Measuring the PG&#160;across the lesion is crucial for assessing hemodynamic changes before and after balloon or stent angioplasty. Additionally, peripheral oxygen levels, cough response, and hemoptysis should be monitored during the procedure for the timely detection of complications.
<ol>
	<li>Choose an appropriately sized balloon based on the CTPA and pulmonary venography data, and gradually dilate the most stenotic part of the target vein.</li>
	<li>Remove the balloon delivery catheter.</li>
	<li>Repeat pulmonary venography and pressure measurements. If there are no significant improvements in PG, hemodynamics, or the degree of stenosis, indicating limited effects or acute recoil, proceed with further angioplasty using a stent.</li>
	<li>Select an appropriately sized stent based on the characteristics assessed through&#160;imaging tools.</li>
	<li>Retract the guiding catheter.</li>
	<li>Advance the stent over the guidewire into the dedicated vein and perform the stenting procedure. Confirm the stent location via anatomic landmarks.</li>
	<li>Advance the guiding catheter back to the distal stenotic site to perform repeated pulmonary venography and pressure measurements. If images show inadequate stent expansion and the PG is greater than 5 mmHg, perform post-dilation of the stent.</li>
	<li>At the end of the procedure, perform the final venography to rule out any oozing or perforation and re-evaluate the PG. If the PG is less than 5 mmHg, the procedure is considered&#160;successful.</li>
	<li>Switch the guiding catheter to another stenotic vein, then perform the interventional procedures according to the aforementioned steps.</li>
	<li>Remove the guidewire and transseptal sheath.</li>
	<li>Press the puncture site manually and apply a tight pressure bandage to prevent local bleeding.</li>
</ol>
7. Postintervention care
<ol>
	<li>Continuously monitor vital signs, including blood oxygen saturation, as it is essential for the early detection of post-procedural complications.</li>
	<li>Recommend novel oral anticoagulants or vitamin K antagonists for 6-12 months, and aspirin (100 mg/day) or clopidogrel (75 mg/day) for at least 3-6 months.</li>
	<li>Regular follow-up and surveillance with CTPA are recommended to detect potential in-stent restenosis (ISR).</li>
</ol>

<ol><li>Rossi, S. E., Mcadams, H. P., Rosado-De-Christenson, M. L., Franks, T. J., Galvin, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fibrosing+mediastinitis%5BTitle%5D)+AND+%22Radiographics%22%5BJournal%5D)">Fibrosing mediastinitis.</a> Radiographics. 21 (3), 737-757 (2001).</li>
<li>Lin, J., Jimenez, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Acute+mediastinitis%2C+mediastinal+granuloma%2C+and+chronic+fibrosing+mediastinitis%3A+A+review%5BTitle%5D)+AND+%22Semin+Diagn+Pathol%22%5BJournal%5D)">Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review.</a> Semin Diagn Pathol. 39 (2), 113-119 (2022).</li>
<li>Ponamgi, S. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Catheter-based+intervention+for+pulmonary+vein+stenosis+due+to+fibrosing+mediastinitis%3A+The+mayo+clinic+experience%5BTitle%5D)+AND+%22Int+J+Cardiol+Heart+Vasc%22%5BJournal%5D)">Catheter-based intervention for pulmonary vein stenosis due to fibrosing mediastinitis: The mayo clinic experience.</a> Int J Cardiol Heart Vasc. 8, 103-107 (2015).</li>
<li>Wang, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+hypertension+caused+by+fibrosing+mediastinitis%5BTitle%5D)+AND+%22JACC+Asia%22%5BJournal%5D)">Pulmonary hypertension caused by fibrosing mediastinitis.</a> JACC Asia. 2 (3), 218-234 (2022).</li>
<li>Firouzi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+endovascular+approach+in+adult+patients+with+pulmonary+vein+stenosis%3A+A+state-of-the-art+approach%5BTitle%5D)+AND+%22Curr+Probl+Cardiol%22%5BJournal%5D)">Current endovascular approach in adult patients with pulmonary vein stenosis: A state-of-the-art approach.</a> Curr Probl Cardiol. 47 (6), 100850(2022).</li>
<li>Lee, E. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Proximal+pulmonary+vein+stenosis+detection+in+pediatric+patients%3A+Value+of+multiplanar+and+3-d+vr+imaging+evaluation%5BTitle%5D)+AND+%22Pediatr+Radiol%22%5BJournal%5D)">Proximal pulmonary vein stenosis detection in pediatric patients: Value of multiplanar and 3-d vr imaging evaluation.</a> Pediatr Radiol. 43 (8), 929-936 (2013).</li>
<li>Wang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+vascular+stenosis+scoring+in+fibrosing+mediastinitis%5BTitle%5D)+AND+%22Eur+Heart+J+Imaging+Methods+Pract%22%5BJournal%5D)">Pulmonary vascular stenosis scoring in fibrosing mediastinitis.</a> Eur Heart J Imaging Methods Pract. 2 (1), qyae034(2024).</li>
<li>Duan, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Balloon+angioplasty+or+stent+implantation+for+pulmonary+vein+stenosis+caused+by+fibrosing+mediastinitis%3A+A+systematic+review%5BTitle%5D)+AND+%22Cardiovasc+Diagn+Ther%22%5BJournal%5D)">Balloon angioplasty or stent implantation for pulmonary vein stenosis caused by fibrosing mediastinitis: A systematic review.</a> Cardiovasc Diagn Ther. 9 (5), 520-528 (2019).</li>
<li>Duan, Y. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((short-term+efficacy+and+perioperative+safety+of+catheter-based+intervention+for+pulmonary+vein+stenosis+caused+by+fibrosing+mediastinitis%5BTitle%5D)+AND+%22Zhonghua+Xin+Xue+Guan+Bing+Za+Zhi%22%5BJournal%5D)">short-term efficacy and perioperative safety of catheter-based intervention for pulmonary vein stenosis caused by fibrosing mediastinitis.</a> Zhonghua Xin Xue Guan Bing Za Zhi. 50 (1), 55-61 (2022).</li>
<li>Jia, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+vein+stenosis+with+normal+pulmonary+artery+wedge+pressure%5BTitle%5D)+AND+%22JACC+Cardiovasc+Interv%22%5BJournal%5D)">Pulmonary vein stenosis with normal pulmonary artery wedge pressure.</a> JACC Cardiovasc Interv. 15 (6), e69-e72 (2022).</li>
<li>Zhang, J., Ding, M., Tang, A., Cao, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+rare+sequelae+of+esophageal+perforation%3A+Fibrosing+mediastinitis%5BTitle%5D)+AND+%22Pulm+Circ%22%5BJournal%5D)">A rare sequelae of esophageal perforation: Fibrosing mediastinitis.</a> Pulm Circ. 14 (1), e12329(2024).</li>
<li>Massumi, A., Woods, L., Mullins, C. E., Nasser, W. K., Hall, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+venous+dilatation+in+pulmonary+veno-occlusive+disease%5BTitle%5D)+AND+%22Am+J+Cardiol%22%5BJournal%5D)">Pulmonary venous dilatation in pulmonary veno-occlusive disease.</a> Am J Cardiol. 48 (3), 585-589 (1981).</li>
<li>Qureshi, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcatheter+angioplasty+for+acquired+pulmonary+vein+stenosis+after+radiofrequency+ablation%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation.</a> Circulation. 108 (11), 1336-1342 (2003).</li>
<li>Almakadma, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+vein+stenosis-balloon+angioplasty+versus+stenting%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22JACC+Clin+Electrophysiol%22%5BJournal%5D)">Pulmonary vein stenosis-balloon angioplasty versus stenting: A systematic review and meta-analysis.</a> JACC Clin Electrophysiol. 8 (10), 1323-1333 (2022).</li>
<li>Prieto, L. R., Schoenhagen, P., Arruda, M. J., Natale, A., Worley, S. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+stent+versus+balloon+angioplasty+for+pulmonary+vein+stenosis+complicating+pulmonary+vein+isolation%5BTitle%5D)+AND+%22J+Cardiovasc+Electrophysiol%22%5BJournal%5D)">Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation.</a> J Cardiovasc Electrophysiol. 19 (7), 673-678 (2008).</li>
<li>Schoene, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Acquired+pulmonary+vein+stenosis+after+radiofrequency+ablation+for+atrial+fibrillation%3A+Single-center+experience+in+catheter+interventional+treatment%5BTitle%5D)+AND+%22JACC+Cardiovasc+Interv%22%5BJournal%5D)">Acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation: Single-center experience in catheter interventional treatment.</a> JACC Cardiovasc Interv. 11 (16), 1626-1632 (2018).</li>
<li>Fender, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Severe+pulmonary+vein+stenosis+resulting+from+ablation+for+atrial+fibrillation%3A+Presentation%2C+management%2C+and+clinical+outcomes%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation: Presentation, management, and clinical outcomes.</a> Circulation. 134 (23), 1812-1821 (2016).</li>
<li>Fink, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pulmonary+vein+stenosis+or+occlusion+after+catheter+ablation+of+atrial+fibrillation%3A+Long-term+comparison+of+drug-eluting+versus+large+bare+metal+stents%5BTitle%5D)+AND+%22Europace%22%5BJournal%5D)">Pulmonary vein stenosis or occlusion after catheter ablation of atrial fibrillation: Long-term comparison of drug-eluting versus large bare metal stents.</a> Europace. 20 (10), e148-e155 (2018).</li>
<li>Jia, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Incidence+and+predictors+of+in-stent+restenosis+following+intervention+for+pulmonary+vein+stenosis+due+to+fibrosing+mediastinitis%5BTitle%5D)+AND+%22Orphanet+J+Rare+Dis%22%5BJournal%5D)">Incidence and predictors of in-stent restenosis following intervention for pulmonary vein stenosis due to fibrosing mediastinitis.</a> Orphanet J Rare Dis. 19 (1), 379(2024).</li>
<li>Wang, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prognosis+and+Management+of+Recurrent+Stenosis+After+Pulmonary+Vein+Stenting%3A+A+Prospective+Study%5BTitle%5D)+AND+%22JACC+Clin+Electrophysiol%22%5BJournal%5D)">Prognosis and Management of Recurrent Stenosis After Pulmonary Vein Stenting: A Prospective Study.</a> JACC Clin Electrophysiol. 11 (1), 46-55 (2025).</li>
<li>Denby, K. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+Drug-Coated+Balloon+Angioplasty+in+Pulmonary+Vein+Stenosis+or+Total+Occlusion%5BTitle%5D)+AND+%22JACC+Clin+Electrophysiol%22%5BJournal%5D)">Efficacy of Drug-Coated Balloon Angioplasty in Pulmonary Vein Stenosis or Total Occlusion.</a> JACC Clin Electrophysiol. 10 (8), 1840-1847 (2024).</li>
<li>Varghese, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+retrospective+evaluation+of+the+treatment+effects+of+rituximab+in+patients+with+progressive+and+symptomatic+fibrosing+mediastinitis%5BTitle%5D)+AND+%22Ann+Am+Thorac+Soc%22%5BJournal%5D)">A retrospective evaluation of the treatment effects of rituximab in patients with progressive and symptomatic fibrosing mediastinitis.</a> Ann Am Thorac Soc. 21 (11), 1533-1541 (2024).</li>
</ol>

The authors declare that they have no competing interests.

The critical steps of the interventional procedure include: ensuring safe transseptal access without complications; administering heparin to maintain an activated clotting time of approximately 250-350 seconds to prevent embolic events; utilizing hemodynamic monitoring to guide treatment strategies; and confirming correct guidewire placement through venography to avoid injury to the vessel and adjacent structures. Additionally, it is essential to adequately flush all catheters to prevent air embolism and to carefully sel...

Fibrosing mediastinitis (FM), also known as sclerosing mediastinitis and mediastinal fibrosis, is a rare yet severe disease characterized by abnormal proliferation of fibrous tissue within the mediastinum1,2. The diagnosis of FM is challenging due to its insidious onset and nonspecific symptoms, which may include fatigue, dyspnea, wheezing, chest pain, cough, or hemoptysis, depending on the anatomic structures involved2,3. Thus, definitive diagnosis is typically delayed, and misdiagnosis is frequent. As the disease progresses, compression from fibrous tissue can lead to pulmonary vein stenosis (PVS) or occlusion, eventually resulting in recurrent episodes of pleural effusion, pulmonary hypertension (PH), right heart failure, or even death3,4. Therefore, early diagnosis is of paramount importance for patients with FM-associated PVS5.
To date, computed tomography pulmonary angiography (CTPA) is the primary noninvasive diagnostic approach for PVS and can be utilized to evaluate pulmonary vein (PV) anatomy, lesion characteristics, and comorbidities6. With the aid of CTPA, the number of involved pulmonary veins (PVs) can be characterized, the etiology of PVS can be determined, the location of the stenosis or occlusion can be identified, and the residual diameter of the most stenotic segment can be measured5. Furthermore, three-dimensional volume-rendered (3-D VR) CTPA reconstructions can separate the pure vascular component of anatomical structures from adjacent osseous and lung abnormalities6, thereby enhancing visualization quality. Based on the involvement of pulmonary vessels, the trachea, and bronchi in the mediastinum, FM can be classified into three subcategories: arterial, venous, and mixed7. These are also referred to as type I, type II, and type III4. Type I (arterial) FM indicates stenosis of the pulmonary arteries (PAs) but not the PVs and is typically accompanied by stenosis of anatomically adjacent bronchi. Type II (venous) FM indicates stenosis of the PVs without involvement of the PAs, and bronchial involvement is uncommon. Type III (mixed) FM involves stenosis of the PAs, PVs, and bronchi.
Currently, drug therapy for FM-associated PVS is palliative and has limited efficacy, while surgical treatment is associated with a significant risk of mortality8. As an emerging technique, catheter-based intervention serves as a viable alternative for patients suffering from PVS; timely angioplasty effectively alleviates obstruction, thereby normalizing venous flow into the left atrium and yielding significant improvements in outcomes based on studies with small sample sizes3,9. However, formulating treatment strategies for FM-associated PVS is challenging and requires consideration of the holistic functioning of both PAs and PVs7, as well as the involvement of adjacent structures such as the lung parenchyma, bronchi, esophagus, and pericardium. Additionally, comorbidities, the patient&#39;s clinical history, and their current condition must be taken into account. Generally, for mixed FM, it is recommended to prioritize PV intervention7. Once the stenosed PV has been successfully reopened, PA intervention can be considered promptly. However, if the occlusion of the PV cannot be resolved, PA intervention should be avoided. Similarly, if it is anticipated that the occlusion of the PA cannot be alleviated, PV intervention should not be pursued. Based on previous treatment experiences9,10,11, the endovascular approach is recommended for PVS caused by FM (PVS-FM).
However, owing to the complexity of treatment strategies and the absence of standardization for interventional procedures, the clinical application of this technique is limited. This study elucidates a stepwise approach for the transcatheter procedure in a patient with FM-associated PVS. The patient was a 77-year-old man who presented with exertional dyspnea and recurrent episodes of unilateral pleural effusion for 3 years. His past medical history was unremarkable, with no evidence of cardiovascular disease, infectious disease, immune system disorders, or a history of radiotherapy exposure or chest surgery. CTPA was performed at the time of admission, and the patient was diagnosed with mixed FM (type III). He had been undergoing drug therapy, but it had shown limited efficacy. Owing to the high mortality risk associated with surgery and the ineffectiveness of drug therapy, as well as the patient&#39;s preference for minimally invasive procedures, we planned to perform transcatheter pulmonary vessel angioplasty to alleviate symptoms. Considering the involvement of PVs, PAs, bronchi, and recurrent episodes of pleural effusion, as well as the possibility of recanalization of the stenotic PA, a therapeutic strategy for PV intervention was first developed by the intervention team.

<table><tbody><tr><td>Guiding Catheter&amp;nbsp; 6 F JR 4.0</td><td>Cordis</td><td>670-080-00</td><td>guiding catheter</td></tr><tr><td>FAST-CATH&lt;sup&gt;TM&lt;/sup&gt; Transseptal Guiding Introducer 8.5 F</td><td>Abbott</td><td>406849</td><td>transseptal procedure</td></tr><tr><td>BRK&lt;sup&gt;TM&lt;/sup&gt; Transseptal Needle&amp;nbsp;</td><td>Abbott</td><td>407200</td><td>transseptal procedure</td></tr><tr><td>Runthrough NS Extra Floppy PTCA Guide Wire - 0.014&#039;&#039; 180 cm</td><td>Terumo</td><td>TW-AS418XA</td><td>guide wire</td></tr><tr><td>Guide Wire - 0.035&#039;&#039; 150 cm</td><td>Cordis</td><td>520-521</td><td>guide wire</td></tr><tr><td>Sterling&lt;sup&gt;TM&lt;/sup&gt; MONORALLTM PTA Balloon Dilatation Catheter 5.0 mm &amp;times; 20 mm</td><td>Boston Scientific</td><td>H74939031502010</td><td>balloon angioplasty</td></tr><tr><td>Sterling&lt;sup&gt;TM&lt;/sup&gt; MONORALLTM PTA Balloon Dilatation Catheter 7.0 mm &amp;times; 30 mm</td><td>Boston Scientific</td><td>H74939031703010</td><td>balloon angioplasty</td></tr><tr><td>Express&lt;sup&gt;TM&lt;/sup&gt; Vascular SD Premounted Stent System 7.0 mm &amp;times; 19 mm</td><td>Boston Scientific</td><td>H74937918719150</td><td>stenting</td></tr><tr><td>Coronary Control Syringe 12 ml</td><td>Allwell Medical Corporation</td><td>CCS600/A</td><td>flush syringe</td></tr><tr><td>Everest Inflation Device</td><td>Medtronic</td><td>AC3200</td><td>pressure pump&amp;nbsp;</td></tr><tr><td>AVANTI Introducer - 8F 11 cm</td><td>Cordis</td><td>504-608X</td><td>catheter sheath</td></tr></tbody></table>

catheter-based endovascular angioplasty for fibrosing mediastinitis-associated pulmonary vein stenosis

Catheter-based Endovascular Angioplasty for Fibrosing Mediastinitis-associated Pulmonary Vein Stenosis

Fibrosing mediastinitis (FM) is a rare but severe disease characterized by abnormal proliferation of fibrous tissue within the mediastinum. Pulmonary vein stenosis (PVS) is a life-threatening complication of FM, with a poor prognosis if not properly treated. Currently, catheter-based endovascular angioplasty is an alternative for patients suffering from PVS and has demonstrated significant short-term efficacy. The main steps of this technique include evaluating the structures involved in the mediastinum via computed tomography pulmonary angiography (CTPA), establishing transseptal access, performing selective pulmonary venography, conducting balloon angioplasty and stent implantation for the pulmonary veins, monitoring hemodynamic parameters before, during, and after endovascular angioplasty, and providing post-intervention care and routine follow-up. This study discusses the formulation of interventional strategies based on the characteristics of compressed pulmonary vessels and adjacent structures in CTPA, as well as the possible periprocedural complications and corresponding management strategies. This article primarily presents a step-by-step demonstration of catheter-based endovascular angioplasty for PVS caused by FM (PVS-FM).

In this study, catheter-based endovascular angioplasty was successfully performed on a patient with FM-associated PVS. Improvements were observed in the stenotic vessels following the procedure, including achievement of patency in the target veins with flow grade 3, and decreased PG across the stenoses. The hemodynamic parameters before and after the angioplasty are presented in Table 1. Symptoms of dyspnea were relieved at discharge, along with an improvement in exercise capacity. Long-term follow-up is...

Pulmonary vein stenosis (PVS) is a life-threatening complication of fibrosing mediastinitis (FM), with a poor prognosis if not properly treated. Currently, catheter-based endovascular angioplasty is a promising therapeutic strategy for FM-associated PVS. This protocol primarily outlines a stepwise approach to the transcatheter procedure for FM-associated PVS.

Fibrosing mediastinitis (FM) is a rare but severe disease characterized by abnormal proliferation of fibrous tissue within the mediastinum. Pulmonary vein ...

This study primarily focused on pulmonary vein stenosis caused by fibrosing mediastinitis, and mainly presents the interventional treatment steps for pulmonary vein stenosis for a beginner's reference and learning. The latest research identifies the pulmonary vein diameter and the corresponding pulmonary artery stenosis as predictors of restenosis. Our cohort study confirms re-stenting is more effective than balloon dilation for restenosis.I think drug-eluting balloons could be an effective solution for restenosis and prospective studies are need to confirm this. Pulmonary vein intervention requires atrial septum puncture, and in these patients, the left atrium is often smaller. Additionally, selective pulmonary vein angiography is performed in retrograde flow, increasing difficulty.I proposed the dural triple sign and Yunshan's sign for fibrosing mediastinitis screening, along with a clinical classification and a stenosis scoring system for preoperative assessments. To begin, assist a patient in lying down on their back. Record the electrocardiogram, heart rate, peripheral oxygen saturation, and blood pressure.Next, connect 500 milliliters of normal saline to the peripheral venous access line. Flush all the catheters with heparinized saline to prevent thromboembolic complications. To establish femoral vein access, first, insert an eight French catheter sheath into the right femoral vein on the sterilized right groin.Insert a 0.035 inch guidewire. Deliver the guiding catheter to the right superior pulmonary artery via the guidewire. Then, withdraw the guidewire.Perform selective right superior pulmonary artery angiography to establish the location of the left atrium in the 45 degree right anterior oblique view. For transseptal catheterization, insert a 0.032 inch J-tip guidewire into the superior vena cava. Then, remove the eight French catheter sheath.Advance the transseptal guiding sheath dilator assembly into the superior vena cava over the J-tip guidewire under anterior posterior fluoroscopy. Remove the guidewire from the dilator. Advance the transseptal needle into the dilator.Position the transseptal needle and stylet assembly until the stylet is positioned just proximal to the dilator tip inside the sheath. Then, remove the stylet. Next, retract the entire assembly and adjust the pointer flange so that the needle is positioned perpendicular to the fossa ovalis in the anterior-posterior view.Use fluoroscopy to verify that the needle tip is within the dilator. Visualize and identify anatomic landmarks in the 45 degree right anterior oblique view. Then, extend the needle to full engagement within the sheath dilator assembly.Advance it across the interatrial septum. Maintain a fixed needle position within the left atrium. Then, advance the sheath dilator assembly fully over the needle into the left atrial cavity.Remove the transseptal needle from the dilator. Next, insert a 0.035 inch guidewire and advance it into the left superior pulmonary vein. Advance the sheath fully into the left atrial cavity over the dilator.Then, withdraw the dilator. Now, insert the guiding catheter, advance it into the left atrium over the guidewire and withdraw the guidewire. Measure the left atrial pressure via the guiding catheter.To begin, monitor the vitals of a patient with fibrosing mediastinitis-associated pulmonary vein stenosis. Insert a 0.014 inch Runthrough guidewire into the distal left superior pulmonary vein. Gently pass the guiding catheter over the wire.Position its tip at the distal part of the stenosis. Perform selective pulmonary venography to evaluate the lesion's location, severity of stenosis, and grade of pulmonary vein flow. Record pressure measurements of the distal part of the stenosis.Retract the JR guiding catheter to the proximal part. Then, measure the proximal pressure and calculate the pressure gradient between the two sides of the lesion. For balloon angioplasty and stent implantation, first, choose an appropriately sized balloon based on computed tomography pulmonary angiography and pulmonary venography data.Perform gradual dilation at the most stenotic part of the vein. Then, remove the balloon delivery catheter and repeat angiography. Retract the guiding catheter.Advance an appropriately sized stent over the guidewire into the stenotic vein. Then, perform the stenting procedure. Finally, remove the guidewire and transseptal sheath.Press the puncture site manually and apply an elastic bandage to prevent bleeding. The catheter-based endovascular angioplasty resulted in a significant reduction in the pressure gradient across the stenotic lesions.

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JoVE Journal

Medicine

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Learn catheter-based endovascular angioplasty for fibrosing mediastinitis-associated pulmonary vein stenosis. This method demonstrates re-stenting techniques and transseptal catheterization procedures for improved patient outcomes.

Catheter-based Endovascular Angioplasty for Fibrosing Mediastinitis-associated Pulmonary Vein Stenosis

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