CHEST Guidelines-A-46-Year-Old-Man-With-Dyspnea,-Hypoxemia,-and-Rad (1)

A-46-Year-Old-Man-With-Dyspnea,-Hypoxemia,-and-Rad (1)

Pdf Summary

The case details a 46-year-old man who experienced complications following a redo bilateral sequential lung transplantation, performed due to rapidly progressive bronchiolitis obliterans syndrome. Following the surgery, the patient showcased symptoms of dyspnea, hypoxemia, and radiographic asymmetry, alongside elevated pulmonary arterial pressures. Diagnostic efforts showed an elevated flow velocity in the pulmonary veins and asymmetric pulmonary infiltrates, leading to the identification of left pulmonary artery anastomotic stenosis.<br /><br />The case discussion highlights pulmonary hypertension as a pathological development after lung allograft reperfusion, often resulting from primary graft dysfunction (PGD). However, in cases without typical signs of PGD, such as asymmetric infiltrates, vascular complications like anastomotic stenosis are considered. Vascular complications are rare but significant in lung transplants, with identified risk factors including surgical technique and donor-size mismatches.<br /><br />In this situation, diagnostic tools such as transesophageal echocardiography, CT angiography, and perfusion scans are employed to identify and assess pulmonary vasculature issues. For this patient, the elevated pulmonary venous flow velocity suggested the necessity to check venous anastomoses before considering arterial anomalies.<br /><br />The clinical course involved a surgical repair of the stenosed left pulmonary artery post-surgery, which included a pulmonary arterioplasty using bovine pericardium, ultimately resolving the issue. The patient recovered well with improved blood flow distribution between the lungs and exhibited good quality of life afterward.<br /><br />Key takeaways include the importance of promptly identifying and treating pulmonary vascular anastomotic complications to mitigate morbidity and mortality, utilizing a combination of echocardiography and imaging modalities for diagnosis, and understanding common surgical pitfalls and considerations in lung transplantation.

Keywords

lung transplantation

bronchiolitis obliterans syndrome

pulmonary hypertension

anastomotic stenosis

primary graft dysfunction

vascular complications

transesophageal echocardiography

pulmonary arterioplasty

bovine pericardium

pulmonary vasculature