Abstract

Fibrosing mediastinitis (FM) is a rare but fatal disease characterized by an excessive fibrotic reaction in the mediastinum, which can lead to life-threatening stenosis of the pulmonary veins (PV). Catheter-based intervention is currently the only viable option for therapy. However, the current literature on how best to manage these difficult cases, especially in regards to sequential interventions and their potential complications is very limited. We searched through a database of all patients who have undergone PV interventions at the Earl H. Wood Cardiac Catheterization Laboratory in Mayo Clinic, Rochester. From this collection, we selected patients that underwent PV intervention to relieve stenosis secondary to FM. Eight patients were identified, with a mean age of 41 years (24–59 years). Five were men, and three were women. Three patients underwent balloon angioplasty alone, and five patients had stents placed. The majority of patients had acute hemodynamic and symptomatic improvement. More than one intervention was required in five patients, four patients had at least one episode of restenosis, and four patients died within four weeks of their first PV intervention. We describe the largest reported case series of catheter-based intervention for PV stenosis in FM. Although catheter-based therapy improved hemodynamics, short-term vascular patency, and patient symptoms, the rate of life-threatening complications, restenosis, and mortality associated with these interventions was found to be high. Despite these associated risks, catheter-based intervention is the only palliative option available to improve quality of life in severely symptomatic patients with PV stenosis and FM. Patients with PV stenosis and FM (especially those with bilateral disease) have an overall poor prognosis in spite of undergoing these interventions due to the progressive and recalcitrant nature of the disease. This underscores the need for further innovative approaches to manage this disease.

Abstract

Clot embolism remains a concern due to flushing of clot and thrombolytic agent centrally in the process of percutaneous pharmacomechanical thrombolysis (PMT) for a thrombosed prosthetic arteriovenous access (PAVA), which might be reduced by a modified technique. We retrospectively review this modified technique that uses two balloon-catheters in crisscross fashion and occludes both ends of PAVA during thrombolysis. Underlying stenotic lesions were dilated simultaneously with balloon angioplasty when needed. Among the 23 patients treated, 21 (91.3%), 10 (43.5%), and seven (30.4%) presented significant stenosis at the outflow, intragraft, and inflow segments of PAVA, respectively. The median duration of follow-up was 310.0 (range, 288.0–327.0) days. Anatomic success was achieved in 12 out of 23 (52.2%). Clinical success for successful dialysis was achieved in all patients. The median primary patency and secondary patency were 126.0 days (range, 7.0–316.0) days and 308.0 days (range, 84.0–327.0), respectively. We believe this method is safe and effective in dissolving PAVA thrombus as well as treating culprit stenosis. It may reduce concerns of flushing of clot and thrombolytic agent into the central circulation in the process of PMT.