I found this study published in March 2001. Dr. Rothman did this exact procedure on me in May 2000 at UCSD.
Treatment of Pulmonary Artery Compression Due to Fibrous Mediastinitis With Endovascular Stent Placement*
Alejandro Guerrero, BA, Eric K. Hoffer, MD, Leonard Hudson, MD, FCCP, Paul Schuler, MD, FCCP and Riyad Karmy-Jones, MD
We present the case of a 32-year-old woman with high-grade right pulmonary artery stenosis secondary to fibrous mediastinitis. The patient was managed with balloon angioplasty and stent placement. Only 15 cases of this nature have been reported in the literature, and this is one of the first to be managed with endovascular stent placement.
Fibrous mediastinitis is a rare condition first described in 1855 by Nathan Oulmont.1 It is typically associated with mycobacterial and mycotic infections.2 Patients typically present with superior vena cava (SVC) syndrome.34 Most cases have a benign clinical course until the lesion constricts a major mediastinal structure.2 Fifteen other cases of fibrous mediastinitis with pulmonary artery compression have been described in the literature.56789101112 In the past 10 years, endovascular approaches have provided an effective treatment option for those individuals suffering from SVC syndrome.1314 Recent advances in endovascular techniques have allowed the dilation and stenting of the pulmonary artery. To our knowledge, only one other case of fibrous mediastinitis has been managed with pulmonary artery endovascular stenting.
A 32-year-old woman from the Mississippi Valley presented with severe shortness of breath and chronic cough. Physical examination demonstrated distended neck veins and symptoms consistent with SVC syndrome. Chest radiograph revealed an area of calcification in the right parasternal region at the level of the third rib (Fig 1 ). A pulmonary perfusion scan was performed that indicated essentially no perfusion to the right lung. A CT scan was performed that revealed a lesion adjacent to the right main pulmonary artery. The patient underwent two mediastinoscopies. Frozen section evaluation and cultures demonstrated a fibrous histology with no evidence of mycobacterial or fungal infection. The patient was prescribed an anti-inflammatory steroid regimen, with some resolution of the SVC syndrome. A CT scan demonstrated a mass approximately 3.0 cm by 2.5 cm by 2.0 cm and SVC stenosis with significant collateral veins. Peripheral administration of contrast was unable to visualize the right pulmonary circulation, so a catheter was employed to administer the contrast proximal to the right pulmonary artery (Fig 2 ). This showed an abrupt stenosis of the right main pulmonary artery. An angiographic study revealed 95% stenosis of the right pulmonary artery at its junction with the right lower pulmonary artery, and total occlusion of the right upper pulmonary artery (Fig 3 ). The stenosis was dilated and stented with a Palmaz 424 medium catheter (Cordis/Johnson and Johnson; Miami, FL) over a 5.8F 10-mm balloon catheter. A poststent angiogram confirmed the appropriate placement of the stent and patency of the right lower and middle pulmonary arteries (Fig 4 ). The patient was prescribed aspirin, 5 grains tid, and discharged.
Shortly after the stent placement, the patient had complete resolution of symptoms. At 3-month follow-up, she had continued absence of symptoms, and a pulmonary perfusion scan indicated appropriate ventilation and perfusion to the right lower and middle lobes.
Fibrous mediastinitis is a rare condition that was recognized as a cause of SVC obstruction by Osler in 1903.3 Cases may be idiopathic or associated with tuberculosis, histoplasmosis, sarcoidosis, silicosis, or other fungal infections.2 Mediastinoscopy is warranted to distinguish this inflammatory process from a malignancy. Patients with fibrous mediastinitis generally have a benign clinical course until a mediastinal structure is compressed.15 The first and most common structure affected is the SVC, but involvement of the pulmonary artery, phrenic nerve, recurrent laryngeal nerve, and pulmonary veins have also been documented.2
SVC stent placement is an effective approach to managing SVC syndrome associated with fibrous mediastinitis.1213 In addition, steroid therapy may be an appropriate option in patients with mild obstruction, or as an adjunct to other treatment approaches, although this has not been established.16
Endovascular pulmonary artery angioplasty has been used extensively in pediatric patients with tetrad of Fallot.17 The use of this approach in treating pulmonary stenosis with fibrous mediastinitis has been employed only recently.11 We believe it is an appropriate option that should be considered when presented with such a condition.
↵ Oulmont, N (1855) Des Oblitérations de la veine cave supérieure. J.B. Ballière. Paris, France:
↵ Fauci, AS, Braunwald, E, Fuselbacher, KJ, et al Harrison’s principles of internal medicine 14th ed. 1998,1476 McGraw-Hill. San Francisco, CA:
↵ Osler, W On obliteration of the superior vena cava. Johns Hopkins Hosp Bull 1903;14,169
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↵ Kandzari, DE, Warner, JJ, O’Laughlin, MP, et al Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis. Catheter Cardiovasc Interv 2000;49,321-324 CrossRefMedlineWeb of Science
↵ Chazova, I, Robbins, I, Loyd, J, et al Venous and arterial changes in pulmonary veno-occlusive disease, mitral stenosis and fibrosing mediastinitis. Eur Respir J 2000;15,116-122 Abstract
↵ Dodds, GA, III, Harrison, JK, O’Laughlin, MP, et al Relief of superior vena cava syndrome due to fibrosing mediastinitis using the Palmaz stent. Chest 1994;106,315-318 Abstract/FREE Full Text
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↵ Horikoshi, M, Ebina, A, Imai, T, et al Retroperitoneal fibrosis with involvement up to the mediastinal space. Nihon Kyobu Shikkan Gakkai Zasshi 1996;34,331-335 Medline
↵ Pihkala, J, Nykanen, D, Freedom, RM, et al Interventional cardiac catheterization. Pediatr Clin North Am 1999;46,441-464