CHEST Guidelines-A-46-Year-Old-Man-With-Dyspnea,-Hypoxemia,-and-Rad (2)

A-46-Year-Old-Man-With-Dyspnea,-Hypoxemia,-and-Rad (2)

Pdf Summary

The case involves a 46-year-old man who underwent a redo bilateral sequential lung transplantation due to rapidly progressing bronchiolitis obliterans syndrome that developed 3.5 years after his initial transplantation. Postoperatively, the patient exhibited signs of persistent hypoxemia and asymmetry on chest radiographs, showing asymmetric pulmonary infiltrates with hyperemia of the right lung and hyperlucency of the left. Despite oxygen therapy and vasodilators, his pulmonary arterial pressures remained elevated, prompting further evaluation.<br /><br />Diagnostic workup included a transesophageal echocardiogram which showed elevated flow velocity in the right pulmonary veins, indicating potential vascular complications rather than primary graft dysfunction (PGD). The CT angiogram and perfusion scans revealed left pulmonary artery anastomotic stenosis, confirmed by asymmetric blood flow with most being directed to the right lung. Typically, PGD is characterized by allograft injury, bilateral infiltrates, and increased pulmonary hypertension. However, the actual cause in this case was linked to vascular complications from the anastomotic procedure.<br /><br />Intraoperative transesophageal echocardiography and timely recognition of elevated pulmonary vein flow velocity facilitated the identification of the left pulmonary artery anastomotic stenosis. On postoperative day 18, surgical repair was elected over balloon angioplasty or stenting to avoid complications. A left pulmonary arterioplasty, using bovine pericardium, successfully widened the stenosis and resolved pulmonary hypertension. This intervention restored blood flow balance between the lungs, and the patient eventually made a full recovery with improved quality of life.<br /><br />The case underlines the importance of recognizing and promptly addressing pulmonary vascular anastomotic complications post-transplantation to prevent significant morbidity and mortality. It also highlights the utility of advanced imaging techniques for early detection and management of such complications.

Keywords

lung transplantation

bronchiolitis obliterans syndrome

hypoxemia

pulmonary artery stenosis

transesophageal echocardiogram

vascular complications

pulmonary hypertension

anastomotic stenosis

pulmonary arterioplasty

advanced imaging techniques