Successful Transcatheter Recanalization of a Chronically Occluded Left Pulmonary Artery Due to Fibrosing Mediastinitis

A59-year-old woman presented with fibrosing mediastinitis from prior coccidioidomycosis infection causing severe bilateral proximal branch pulmonary artery (PA) obstruction and right ventricular hypertension. Bilateral PA stents were placed 12 years ago. Ten years ago, the left PA stent was completely occluded and the right stent severely stenotic. A surgical right ventricle-PA homograft was placed to the right PA distal to the stent and the left PA abandoned. Cardiac computed tomography showed no flow through the left PA stent and minimal flow through the right stent (Figure 1). She required chronic supplemental oxygen and had dyspnea with walking for 10 years, which recently worsened, and was referred for left PA recanalization. Right ventricular systolic pressure was elevated (70 mm Hg) with no gradient through the homograft. There was external compression of the left PA stent and a bird's beak appearance to the proximal left PA with no flow through the stent (Figure 2A). Using chronic total occlusion wires and microcatheters in a guide catheter, the left PA stent was traversed (Figure 2B) and a track serially dilated using noncompliant coronary and peripheral bal

Automated summary

A 59-year-old woman presented with fibrosing mediastinitis from prior coccidioidomycosis infection causing severe bilateral proximal branch pulmonary artery (PA) obstruction and right ventricular hypertension. Bilateral PA stents were placed 12 years ago. Ten years ago, the left PA stent was completely occluded and the right stent severely stenotic. A surgical right ventricle-PA homograft was placed to the right PA distal to the stent and the left PA abandoned. Cardiac computed tomography showed no flow through the left PA stent and minimal flow through the right stent. She required chronic supplemental oxygen and had dyspnea with walking for 10 years, which recently worsened, and was referred for left PA recanalization. Right ventricular systolic pressure was elevated (70 mm Hg) with no gradient through the homograft. There was external compression of the left PA stent and a bird's beak appearance to the proximal left PA with no flow through the stent. Using chronic total occlusion wires and microcatheters in a guide catheter, the left PA stent was traversed and a track serially dilated using noncompliant coronary and peripheral bal.