Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis

Abstract

Purpose

Fibrosing mediastinitis is a rare disease characterized by fibrosis of mediastinal structures with subsequent constriction of the bronchi and pulmonary vessels leading to potential respiratory compromise and death. Presently, there is no effective curative treatment with available treatments focused on reducing symptomology, including placement of pulmonary artery stents. Limited studies examine the use of stents in fibrosing mediastinitis. Given this knowledge gap, we assessed stent patency, hemodynamics, complications, and secondary outcomes of clinical improvement of pulmonary artery stenting for fibrosing mediastinitis.

Materials and Methods

Nine patients with fibrosing mediastinitis and pulmonary artery stents were retrospectively identified for inclusion (six females, three males; mean age 44.17 years, range 13–68; total 13 primary stents) from 2005 to 2018. Eight patients had history of PH. All patients had dyspnea on presentation. Seven patients had ventilation/perfusion studies demonstrating impairment. Results from computed tomography and echocardiography studies were collected to assess patency and physiologic response.

Results

All patients received initial angioplasty and stenting of the right pulmonary artery (10 stents). Two patients underwent additional left-sided intervention (3 stents). Stenting significantly increased lesion luminal patency (54–79%; P < 0.005) and reduced systolic pressure gradients across stenoses (mean −9.38 mmHg; P < 0.005). Primary patency at one year was 90%. Two stents received reintervention at 276 and 497 days. 89% reported improvement in dyspnea in the initial post-stenting period. There were no mortalities or major complications.

Conclusion

Pulmonary artery stenting improves vascular patency and provides symptomatic relief in patients with fibrosing mediastinitis.

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References

  1. 1.

    Kauffman CA. Histoplasmosis: a clinical and laboratory update. Clin Microbiol Rev. 2007;20(1):115–32. https://doi.org/10.1128/cmr.00027-06.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Schowengerdt CG, Suyemoto R, Main FB. Granulomatous and fibrous mediastinitis: a review and analysis of 180 cases. J Thorac Cardiovas Surg. 1969;57(3):365–79.

    CAS  Article  Google Scholar 

  3. 3.

    Berry DF, Buccigrossi D, Peabody J, Peterson KL, Moser KM. Pulmonary vascular occlusion and fibrosing mediastinitis. Chest. 1986;89(2):296–301.

    CAS  Article  Google Scholar 

  4. 4.

    Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, et al. Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore). 2011;90(6):412–23. https://doi.org/10.1097/MD.0b013e318237c8e6.

    Article  Google Scholar 

  5. 5.

    Loyd JE, Tillman BF, Atkinson JB, Des Prez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine (Baltimore). 1988;67(5):295–310. https://doi.org/10.1097/00005792-198809000-00002.

    CAS  Article  Google Scholar 

  6. 6.

    Mathisen DJ, Grillo HC. Clinical manifestation of mediastinal fibrosis and histoplasmosis. Ann Thorac Surg. 1992;54(6):1053–8.

    CAS  Article  Google Scholar 

  7. 7.

    Brown ML, Cedeno AR, Edell ES, Hagler DJ, Schaff HV. Operative strategies for pulmonary artery occlusion secondary to mediastinal fibrosis. Ann Thorac Surg. 2009;88(1):233–7. https://doi.org/10.1016/j.athoracsur.2009.04.012.

    Article  PubMed  Google Scholar 

  8. 8.

    Fender EA, Widmer RJ, Knavel Koepsel EM, Welby JP, Kern R, Peikert T, et al. Catheter based treatments for fibrosing mediastinitis. Catheter Cardiovasc Interv Off J Soc Cardiac Angiogr Interv. 2019. https://doi.org/10.1002/ccd.28152.

    Article  Google Scholar 

  9. 9.

    Fogelman R, Nykanen D, Smallhorn JF, McCrindle BW, Freedom RM, Benson LN. Endovascular stents in the pulmonary circulation: clinical impact on management and medium-term follow-up. Circulation. 1995;92(4):881–5.

    CAS  Article  Google Scholar 

  10. 10.

    Lewis MJ, Kennedy KF, Ginns J, Crystal MA, Torres A, Vincent J, et al. Procedural success and adverse events in pulmonary artery stenting: insights from the NCDR. J Am Coll Cardiol. 2016;67(11):1327–35. https://doi.org/10.1016/j.jacc.2016.01.025.

    Article  PubMed  Google Scholar 

  11. 11.

    Kenny D, Amin Z, Slyder S, Hijazi ZM. Medium-term outcomes for peripheral pulmonary artery stenting in adults with congenital heart disease. J Interv Cardiol. 2011;24(4):373–7.

    Article  Google Scholar 

  12. 12.

    Seferian A, Steriade A, Jaïs X, Planché O, Savale L, Parent F, et al. PH complicating fibrosing mediastinitis. Medicine. 2015;94(44):e1800.

    Article  Google Scholar 

  13. 13.

    Doyle TP, Loyd JE, Robbins IM. Percutaneous pulmonary artery and vein stenting: a novel treatment for mediastinal fibrosis. Am J Respir Crit Care Med. 2001;164(4):657–60. https://doi.org/10.1164/ajrccm.164.4.2012132.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Guerrero A, Karmy-Jones R, Hoffer EK, Hudson L, Schuler P. Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement. Chest. 2001;119(3):966–8. https://doi.org/10.1378/chest.119.3.966.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Kandzari DE, Warner JJ, O’Laughlin MP, Harrison JK. Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis. Catheter Cardiovasc Interv. 2000;49(3):321–4.

    CAS  Article  Google Scholar 

  16. 16.

    Fontaine AB, Borsa JJ, Hoffer EK, Bloch RD, So C. Stent placement in the treatment of pulmonary artery stenosis secondary to fibrosing mediastinitis. J Vasc Interv Radiol. 2001;12(9):1107–11. https://doi.org/10.1016/S1051-0443(07)61600-5.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Argueta F, Villafuerte D, Castaneda-Nerio J, Peters J, Restrepo C. Successful management of fibrosing mediastinitis with severe vascular compromise: Report of two cases and literature review. Respir Med Case Rep. 2020;29:100987.

    PubMed  Google Scholar 

  18. 18.

    Satpathy R, Aguila V, Mohiuddin SM, Khan IA. Fibrosing mediastinitis presenting as pulmonary stenosis: stenting works. Int J Cardiol. 2007;118(3):e85–6.

    Article  Google Scholar 

  19. 19.

    Thiessen R, Matzinger F, Seely J, Aina R, MacLeod P. Fibrosing mediastinitis: successful stenting of the pulmonary artery. Canadian respiratory journal. 2008;15:41–4.

    Article  Google Scholar 

  20. 20.

    Ferguson ME, Cabalka AK, Cetta F, Hagler DJ. Results of intravascular stent placement for fibrosing mediastinitis. Congenit Heart Dis. 2010;5(2):124–33. https://doi.org/10.1111/j.1747-0803.2010.00387.x.

    Article  PubMed  Google Scholar 

  21. 21.

    Smith JS, Kadiev S, Diaz P, Cheatham J. Pulmonary artery stenosis secondary to fibrosing mediastinitis: management with cutting balloon angioplasty and endovascular stenting. Vasc Endovasc Surg. 2011;45(2):170–3.

    Article  Google Scholar 

  22. 22.

    Hamilton-Craig C, Slaughter R, McNeil K, Kermeen F, Walters D. Improvement after angioplasty and stenting of pulmonary arteries due to sarcoid mediastinal fibrosis. Heart Lung Circ. 2009;18(3):222–5.

    CAS  Article  Google Scholar 

  23. 23.

    Albers EL, Pugh ME, Hill KD, Wang L, Loyd JE, Doyle TP. Percutaneous vascular stent implantation as treatment for central vascular obstruction due to fibrosing mediastinitis. Circulation. 2011;123(13):1391–9. https://doi.org/10.1161/circulationaha.110.949180.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Crystal MA, Ing FF. Pulmonary artery stents: past, present and future. Prog Pediatr Cardiol. 2012;33(2):151–9.

    Article  Google Scholar 

  25. 25.

    Zablah JE, Morgan GJ. Pulmonary artery stenting. Interv Cardiol Clin. 2019;8(1):33–46.

    PubMed  Google Scholar 

  26. 26.

    Hallbergson A, Lock JE, Marshall AC. Frequency and risk of in-stent stenosis following pulmonary artery stenting. Am J Cardiol. 2014;113(3):541–5.

    Article  Google Scholar 

  27. 27.

    Khalilzadeh O, Baerlocher MO, Shyn PB, Connolly BL, Devane AM, Morris CS, et al. Proposal of a new adverse event classification by the society of interventional radiology standards of practice committee. J Vasc Interv Radiol. 2017;28(10):1432.e3-7.e3.

    Article  Google Scholar 

  28. 28.

    Sherrick AD, Brown LR, Harms GF, Myers JL. The radiographic findings of fibrosing mediastinitis. Chest. 1994;106(2):484–9.

    CAS  Article  Google Scholar 

  29. 29.

    Davis AM, Pierson RN, Loyd JE. Mediastinal fibrosis. Seminars in respiratory infections. 2001;16:119–30.

    CAS  Article  Google Scholar 

  30. 30.

    Westerly BD, Johnson GB, Maldonado F, Utz JP, Specks U, Peikert T. Targeting B lymphocytes in progressive fibrosing mediastinitis. Am J Respir Crit Care Med. 2014;190(9):1069–71.

    Article  Google Scholar 

  31. 31.

    Rossi SE, McAdams HP, Rosado-de-Christenson ML, Franks TJ, Galvin JR. Fibrosing mediastinitis. RadioGraphics. 2001;21(3):737–57. https://doi.org/10.1148/radiographics.21.3.g01ma17737.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    McNeeley MF, Chung JH, Bhalla S, Godwin JD. Imaging of granulomatous fibrosing mediastinitis. Am J Roentgenol. 2012;199(2):319–27.

    Article  Google Scholar 

  33. 33.

    Holzer RJ, Gauvreau K, Kreutzer J, Leahy R, Murphy J, Lock JE, et al. Balloon angioplasty and stenting of branch pulmonary arteries: adverse events and procedural characteristics: results of a multi-institutional registry. Circ Cardiovasc Interv. 2011;4(3):287–96.

    Article  Google Scholar 

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This study was not supported by any funding.

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Correspondence to John P. Welby.

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Welby, J.P., Fender, E.A., Peikert, T. et al. Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis. Cardiovasc Intervent Radiol 44, 384–391 (2021). https://doi.org/10.1007/s00270-020-02714-z

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Keywords

  • Pulmonary artery stent
  • Fibrosing mediastinitis
  • Histoplasmosis