Pulmonary Vein Stenosis-Balloon Angioplasty Versus Stenting: A Systematic Review and Meta-Analysis

Cardiac CT for electrophysiological interventions

Cardiac computed tomography (CCT) holds an important role in the field of electrophysiology offering critical insights that enhance the management of arrhythmias through precise procedural planning and execution. It has furthermore established its role as a useful imaging modality in left atrial appendage closure procedures. This review discusses the current applications of CCT from pre-interventional assessment to post-interventional follow-up, emphasizing its utility in improving the safety and efficacy of electrophysiological and left atrial appendage occlusion interventions. It also explores the integration of CCT with advanced technologies such as electroanatomical mapping systems and the emergence of innovative imaging modalities, including three-dimensional cardiac computational modelling. CCT's evolving capabilities suggest a promising future in electrophysiology and left atrial occlusion procedures when combined with further technological advancements, including artificial intelligence software.

Intravascular Shockwave Lithotripsy: An Adjunct to Balloon Angioplasty for Calcified Pulmonary Vein Stenosis

Pulmonary vein stenosis occurs in 0.4% to 2% of cases after atrial fibrillation ablation. Patients experience chest pain or shortness of breath when pulmonary vein narrowing exceeds 60% or its diameter falls below 4 to 6 mm. To our knowledge, this is the first case report of the use of shockwave intravascular lithotripsy to address calcified pulmonary vein stenosis after the conventional approach of balloon angioplasty failed to result in expansion. Our case highlights that shockwave intravascular lithotripsy is a feasible, safe, and effective adjunctive therapy for treating calcified pulmonary vein stenosis.

Aortic Displacement of a Pulmonary Stent: Multidisciplinary Approach to Treat a Rare Complication

BACKGROUND

Pulmonary vein (PV) stenosis is a rare complication of radiofrequency-based pulmonary vein isolation (PVI). Its therapy consists of PV stenting.

CASE SUMMARY

A 67-year-old woman underwent a thoracic computed tomography scan after left PV stenting for stenosis after PVI. The scan revealed the stent missing in the left inferior PV and worsening high-grade stenosis. An abdominal computed tomography scan identified the displaced stent in the aorta, just above the aortoiliac bifurcation. Digital subtraction angiography also revealed moderate stenosis in the right common iliac artery. A double stenting procedure of the aortoiliac bifurcation using the kissing stents technique was performed, securing the PV stent and treating the common iliac artery stenosis. Follow-up on the displaced stent was favorable.

DISCUSSION AND TAKE-HOME MESSAGE

PV stent systemic displacement is a rare but life-threatening complication of PV stenting. Kissing stents technique is effective to secure the displaced stent in the aortoiliac bifurcation.

Comparing Patency of Pulmonary Stent Implantation and Balloon Angioplasty in Pulmonary Vein Stenosis: A Systematic Review and Meta-Analysis

Pulmonary vein stenosis (PVS) is an insidious diagnosis associated with morbidity and mortality. Pharmacologic therapy may suffice initially, but advanced stages demand mechanical intervention. Pulmonary stent implantation (PSI) and pulmonary balloon angioplasty (PBA) are common strategies, both carrying restenosis risks. This meta-analysis compares PSI and PBA to determine the superior revascularization strategy. We systematically searched databases until November 2023, identifying 11 studies with 780 patients. Studies, including those involving patients undergoing balloon angioplasty (BA) or stent angioplasty (SA) for PVS, were selected. Case reports, editorials, and cross-sectional studies were omitted. Primary outcomes included restenosis requiring reintervention, 5-year freedom from restenosis, and procedure-related complications. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Meta-regression analysis assessed factors like age and stent size. Study quality was evaluated using the Newcastle-Ottawa scale. This Systematic review and meta-analysis incorporated 11 observational studies. PSI exhibited a lower risk of restenosis requiring reintervention (OR 0.34, 95% CI 0.13, 0.87, p = 0.02) and significantly higher 5-year freedom from restenosis (OR 4.42, 95% CI 1.11, 17.62, p = 0.04) compared to PBA, with no significant difference in procedure-related complications. Meta-regression analysis showed age and stent size insignificantly affecting restenosis risk. Our review supports PSI as the preferred revascularization strategy for PVS due to superior patency benefits, emphasizing its role as the initial treatment choice. Further research is warranted for validation, considering individual patient factors in treatment selection.

Prognosis and Management of Recurrent Stenosis After Pulmonary Vein Stenting: A Prospective Study

BACKGROUND

Pulmonary vein stenting is effective for severe pulmonary vein stenosis, which is limited by restenosis. The assessment and management of in-stent restenosis (ISR) are inadequate, and follow-up outcomes after reintervention remain unknown.

OBJECTIVES

This study aimed to assess the prognosis and management of pulmonary vein ISR and determine whether the modified stent-in-stent strategy is superior to balloon angioplasty (BA) in treating ISR.

METHODS

The authors conducted a prospective observational study on patients with severe pulmonary vein stenosis post radiofrequency ablation for atrial fibrillation.

RESULTS

A total of 107 patients with 174 severely stenosed veins underwent successful stenting. Forty-three veins among 36 patients experienced ISR (24.7%, 43 of 174). Veins developing ISR had smaller diameter stents (7.8 ± 0.8 mm vs 9.2 ± 0.7 mm; P = 0.008). Restenosis veins were assigned to BA group or stent-in-stent group. Success rate was 95.7% for BA and 90.0% for stent-in-stent. Twelve veins experienced recurrent ISR, including 2 in stent-in-stent group (11.1%, 2 of 18) and 10 in BA group (45.5%, 10 of 22). The risk of recurrent stenosis was significantly lower in veins treated with the stent-in-stent method than with BA (HR: 0.21; 95% CI: 0.07-0.64; P = 0.02). Patients in the stent-in-stent group had greater exercise endurance and better World Health Organization cardiac functional class compared with BA group (F = 7.2; P < 0.05; and F = 4.4; P < 0.05, respectively) at 6- and 12-month follow-ups.

CONCLUSIONS

Our modified stent-in-stent implantation approach is superior to BA for treating pulmonary vein ISR, by reducing recurrent restenosis rate and improving exercise endurance.

Prevalence and Clinical Implications of Pulmonary Vein Stenosis in Bronchiectasis: A 3D Reconstruction CT Study

BACKGROUND

Recent studies on bronchiectasis have revealed significant structural abnormalities and pathophysiological changes. However, there is limited research focused on pulmonary venous variability and congenital variation. Through our surgical observations, we noted that coarctation of pulmonary veins and atrophied lung volume are relatively common in bronchiectasis patients. Therefore, we conducted a retrospective study to explore pulmonary venous variation and secondary manifestations in bronchiectasis cases, utilizing 3D reconstruction software (Mimics Innovation Suite 21.0, Materialise Dental, Leuven, Belgium) to draw conclusions supported by statistical evidence.

METHOD

This retrospective study included patients with bronchiectasis and healthy individuals who underwent CT examinations at Beijing Chao-Yang Hospital between January 2017 and July 2023. Chest CT data were reconstructed using Materialise Mimics. Pulmonary veins and lung lobes were segmented from surrounding tissue based on an appropriate threshold determined by local grey values and image gradients. Subsequently, venous cross-sectional areas and lung volumes were measured for statistical analysis.

RESULT

CT data from 174 inpatients with bronchiectasis and 75 cases from the health examination center were included. Three-dimensional reconstruction data revealed a significant reduction in cross-sectional areas of pulmonary veins in the left lower lobe (p < 0.001), the right lower lobe (p = 0.030), and the right middle lobe (p = 0.009) of bronchiectasis patients. Subgroup analyses indicated that approximately 73.5% of localized cases of the left lower lobe exhibited pulmonary vein stenosis, while in the diffuse group, this proportion was only 52.6%. Furthermore, the cross-sectional area of pulmonary veins had a gradually decreasing trend, based on a small sample. Lung function tests showed significant reductions in FEV1, FVC, and FEV1% in bronchiectasis patients, attributed to the loss of lung volume in the left lower lobe, which accounted for 60.9% of the included sample.

CONCLUSIONS

Our recent findings suggest that pulmonary venous stenosis is a common variation in bronchiectasis and is often observed concurrently with reduced lung volume, particularly affecting the left lower lobe. Moreover, localized cases are more likely to suffer from pulmonary venous stenosis, with an ambiguous downtrend as the disease progresses. In conclusion, increased attention to pulmonary venous variation in bronchiectasis is warranted, and exploring new therapies to intervene in the early stages or alleviate obstruction may be beneficial.

Case report of the successful treatment of a rare complication of pulmonary vein stenting: atrial rupture and stent detachment

Pulmonary vein stenosis (PVS) is a relatively rare pulmonary vascular disease in clinical practice, and radiofrequency ablation (RFA) is a common cause of pulmonary vein stenosis. Owing to its nonspecific symptoms and irregular follow-up, PVS is often misdiagnosed. In severe cases, intervention is needed, with the main treatment options being pulmonary vein stenting and/or balloon dilation, both of which carry risks of serious complications. We report a patient with severe pulmonary vein stenosis who experienced right atrial wall rupture and stent detachment during an interventional procedure. Through active intraoperative intervention, we successfully avoided serious complications.

Incidence and predictors of in-stent restenosis following intervention for pulmonary vein stenosis due to fibrosing mediastinitis

BACKGROUND

Fibrosing mediastinitis (FM) is a rare yet fatal condition, caused by different triggers and frequently culminating in the obstruction of the pulmonary vasculature and airways, often leading to pulmonary hypertension and right heart failure. Percutaneous transluminal pulmonary venoplasty (PTPV) is an emerging treatment for pulmonary vein stenosis (PVS) caused by FM. Our previous study showed as high as 24% of in-stent restenosis (ISR) in FM. However, the predictors of ISR are elusive.

OBJECTIVES

We sought to identify the predictors of ISR in patients with PVS caused by extraluminal compression due to FM.

METHODS

We retrospectively enrolled patients with PVS-FM who underwent PTPV between July 1, 2018, and December 31, 2022. According to ISR status, patients were divided into two groups: the ISR group and the non-ISR group. Baseline characteristics (demographics and lesions) and procedure-related information were abstracted from patient records and analyzed. Univariate and multivariate analyses were performed to determine the predictors of ISR.

RESULTS

A total of 142 stents were implanted in 134 PVs of 65 patients with PVS-FM. Over a median follow-up of 6.6 (3.4-15.7) months, 61 of 134 PVs suffered from ISR. Multivariate analysis demonstrated a significantly lower risk of ISR in PVs with a larger reference vessel diameter (RVD) (odds ratio (OR): 0.79; 95% confidence interval [CI]: 0.64 to 0.98; P = 0.032), and stenosis of the corresponding pulmonary artery (Cor-PA) independently increased the risk of restenosis (OR: 3.41; 95% CI: 1.31 to 8.86; P = 0.012). The cumulative ISR was 6.3%, 21.4%, and 39.2% at the 3-, 6-, and 12-month follow-up, respectively.

CONCLUSION

ISR is very high in PVS-FM, which is independently associated with RVD and Cor-PA stenosis.

TRAIL REGISTRATION

Chinese Clinical Trials Register; No.: ChiCTR2000033153. URL: http://www.chictr.org.cn .

Comprehensive review of pulmonary vein stenosis post-atrial fibrillation ablation: diagnosis, management, and prognosis

Pulmonary vein stenosis (PVS) can occasionally occur in the follow-up after pulmonary vein isolation (PVI) for atrial fibrillation (AF). During PVI, ablation is performed at the PV ostium or distal part, leading to tissue damage. This damage can result in fibrosis of the necrotic myocardium, proliferation, and thickening of the vascular intima, as well as thrombus formation, further advancing PVS. Mild-to-moderate PVS often remains asymptomatic, but severe PVS can cause symptoms, such as dyspnea, cough, fatigue, decreased exercise tolerance, chest pain, and hemoptysis. These symptoms are due to pulmonary hypertension and pulmonary infarction. Imaging evaluations such as contrast-enhanced computed tomography are essential for diagnosing PVS. Early suspicion and detection are necessary, as underdiagnosis can lead to inappropriate treatment, disease progression, and poor outcomes. The long-term prognosis of PVS remains unclear, particularly regarding the impact of mild-to-moderate PVS over time. PVS treatment focuses on symptom management, with no established definitive solutions. For severe PVS, transcatheter PV angioplasty is performed, though the risk of restenosis remains high. Restenosis and reintervention rates have improved with stent implantation compared with balloon angioplasty. The role of subsequent antiplatelet therapy remains uncertain. Dedicated evaluation is essential for accurate diagnosis and appropriate management to avoid significant long-term impacts on patient outcomes.

Pulmonary vein stenosis following radiofrequency pulmonary vein isolation: Presentation, diagnosis, and management using self-expandable, bare metal stents

Pulmonary vein (PV) stenosis is a rare complication following PV isolation (PVI) for atrial fibrillation. Despite the benefit of early intervention, screening is not conducted, emphasizing the importance of maintaining a high index of suspicion. Standardized management approaches are unavailable for this serious complication. This report presents the case of a 56-year-old male with PV stenosis following PVI. During an annual follow up, the patient was asymptomatic, however a left pleural effusion was noted. Subsequent investigations, including a cardiac computed tomography (CT), confirmed the presence of left superior and inferior PV stenosis. Balloon angioplasty (BA) of both PVs was performed, followed by stenting of the left inferior PV with a balloon-expandable bare metal stent (BMS). The stent slipped shortly after deployment requiring snaring and removal. Re-stenosis was confirmed on repeat CT and successful stenting with self-expandable BMSs was performed. Dual anti-platelet treatment was prescribed post-procedure, with lifelong single anti-platelet therapy after 3 months. Patent PVs with stents in-situ were noted on CT three months post-stenting. A recognized consensus among the literature favors stenting over BA, however, no prospective studies have demonstrated the superiority of drug-eluting stents versus BMSs, or balloon-expandable against self-expandable stents. Effective management requires a tailored, multidisciplinary approach.

Learning objectives

Pulmonary vein (PV) stenosis is a rare complication of PV isolation ablation for atrial fibrillation with no guideline-directed treatment protocols. Maintaining a high index of suspicion for PV stenosis is essential to ensure timely intervention to improve lung perfusion and alleviate symptoms. Our case demonstrates the superiority of stenting over balloon angioplasty in maintaining PV patency following stenosis, as well as the successful application of self-expandable stents following slippage of a balloon-expandable stent.

Hybrid Interventions in Congenital Heart Disease: A Review of Current Practice and Rationale for Use

BACKGROUND

Hybrid interventions have become a common option in the management for a variety of patients with congenital heart disease. In this review, we discuss the data that have driven decision making about hybrid interventions to date.

METHODS

The existing literature on various hybrid approaches was reviewed and summarized. In addition, the key tenants to creating a successful hybrid program within a congenital heart center are elucidated.

RESULTS

Hybrid strategies for single-ventricle patients, pulmonary atresia with intact ventricular septum, branch pulmonary artery stenosis, and muscular ventricular septal defect closure have important benefits and limitations compared with traditional approaches.

CONCLUSION

A growing body of evidence supports the use of hybrid interventions in congenital heart disease. But important questions remain regarding improved survival and other long-term outcomes, such as neurocognition, that might impact widespread adoption as a primary treatment strategy.

Patient-specific 3D in vitro modeling and fluid dynamic analysis of primary pulmonary vein stenosis

Introduction

Primary pulmonary vein stenosis (PVS) is a rare congenital heart disease that proves to be a clinical challenge due to the rapidly progressive disease course and high rates of treatment complications. PVS intervention is frequently faced with in-stent restenosis and persistent disease progression despite initial venous recanalization with balloon angioplasty or stenting. Alterations in wall shear stress (WSS) have been previously associated with neointimal hyperplasia and venous stenosis underlying PVS progression. Thus, the development of patient-specific three-dimensional (3D) in vitro models is needed to further investigate the biomechanical outcomes of endovascular and surgical interventions.

Methods

In this study, deidentified computed tomography images from three patients were segmented to generate perfusable phantom models of pulmonary veins before and after catheterization. These 3D reconstructions were 3D printed using a clear resin ink and used in a benchtop experimental setup. Computational fluid dynamic (CFD) analysis was performed on models in silico utilizing Doppler echocardiography data to represent the in vivo flow conditions at the inlets. Particle image velocimetry was conducted using the benchtop perfusion setup to analyze WSS and velocity profiles and the results were compared with those predicted by the CFD model.

Results

Our findings indicated areas of undesirable alterations in WSS before and after catheterization, in comparison with the published baseline levels in the healthy in vivo tissues that may lead to regional disease progression.

Discussion

The established patient-specific 3D in vitro models and the developed in vitro-in silico platform demonstrate great promise to refine interventional approaches and mitigate complications in treating patients with primary PVS.

Pulmonary Vein Intervention for Severe Pulmonary Vein Stenosis After Atrial Fibrillation Ablation - A Retrospective Cohort Study

BACKGROUND

Pulmonary vein (PV) stenosis (PVS) is a serious complication of atrial fibrillation (AF) ablation. The objective of this study was to describe interventional treatments for PVS after AF ablation and long-term outcomes in Japanese patients.

METHODS AND RESULTS

This multicenter retrospective observational study enrolled 30 patients (26 [87%] male; median age 55 years) with 56 severe PVS lesions from 43 PV interventional procedures. Twenty-seven (90%) patients had symptomatic PVS and 19 (63%) had a history of a single AF ablation. Of the 56 lesions, 41 (73%) were de novo lesions and 15 (27%) were retreated. Thirty-three (59%) lesions were treated with bare metal stents, 14 (25%) were treated with plain balloons, and 9 (16%) were treated with drug-coated balloons. All lesions were successfully treated without any systemic embolic event. Over a median follow-up of 584 days (interquartile range 265-1,165 days), restenosis rates at 1 and 2 years were 35% and 47%, respectively. Multivariate Cox regression analysis revealed devices <7 mm in diameter (hazard ratio [HR] 2.52; 95% confidence interval [CI] 1.04-6.0; P=0.040) and totally occluded lesions (HR 3.33; 95% CI 1.21-9.15; P=0.020) were independent risk factors for restenosis.

CONCLUSIONS

All PVS lesions were successfully enlarged by the PV intervention; however, restenosis developed in approximately half the lesions within 2 years.

Improving Outcomes in Pulmonary Vein Stenosis: Novel Pursuits and Paradigm Shifts

Pulmonary vein stenosis (PVS) remains a clinical challenge, with progressive restenosis being common. In the past five years, we have seen an exponential increase in both clinical and scientific publication related to PVS. Central to progress in PVS clinical care is the paradigm shift towards collaborative, multidisciplinary care that utilizes a multimodality approach to treatment. This manuscript will discuss recent conceptual gains in PVS treatment and research while highlighting important outstanding questions and barriers.

Current biofabrication methods for vascular tissue engineering and an introduction to biological textiles

Cardiovascular diseases are the leading cause of mortality in the world and encompass several important pathologies, including atherosclerosis. In the cases of severe vessel occlusion, surgical intervention using bypass grafts may be required. Synthetic vascular grafts provide poor patency for small-diameter applications (< 6 mm) but are widely used for hemodialysis access and, with success, larger vessel repairs. In very small vessels, such as coronary arteries, synthetics outcomes are unacceptable, leading to the exclusive use of autologous (native) vessels despite their limited availability and, sometimes, quality. Consequently, there is a clear clinical need for a small-diameter vascular graft that can provide outcomes similar to native vessels. Many tissue-engineering approaches have been developed to offer native-like tissues with the appropriate mechanical and biological properties in order to overcome the limitations of synthetic and autologous grafts. This review overviews current scaffold-based and scaffold-free approaches developed to biofabricate tissue-engineered vascular grafts (TEVGs) with an introduction to the biological textile approaches. Indeed, these assembly methods show a reduced production time compared to processes that require long bioreactor-based maturation steps. Another advantage of the textile-inspired approaches is that they can provide better directional and regional control of the TEVG mechanical properties.

Percutaneous Structural Interventions in Adult Congenital Heart Disease: State-of-the-Art Review

Structural interventions play a crucial role in the management of adult congenital heart disease (ACHD). In recent years, this field has seen significant advancements in catheter-based procedures despite limited investment from industry and lack of device development specific to this population. Because each patient is unique in their anatomy, pathophysiology, and surgical repair, many devices are used off-label with a "best fit" strategy. Therefore, continuous innovation is needed to adapt what is available to ACHD and to increase collaboration with industry and regulatory bodies to develop dedicated equipment. These innovations will further advance the field and offer this growing population less invasive options with fewer complications and faster recovery times. In this article, we summarize some of the contemporary structural interventions performed in adults with congenital defects and present cases performed at Houston Methodist to better illustrate them. We aim to offer a greater understanding of the field and stimulate interest in this rapidly growing specialty.