D .I

_~I_L_~--“I-.

01990 by the American

._-_ .___^” . .-_I- .-.-..-...^ ^_._.._

College of Cardiology

-..l^l *^__.-“-._ . .._

“__..I.“. _

,___

.,_._^“_“.______ _______

Ill0

ROTHMAN ET AL. BALLOON DILATION OF PULMONARY

JACC Vol. IS. No. 5 -17 April I

AKTEKY STENOSES

measured (with relation to known cat optimally angled angiog~~bi~ views. the worse lesion is dilated first, beta causes the smallest decrease in

ToF TohP4 k&cd PPS other S/P fruncus arteriosus repair SV. S/P shunt SV. SIP Fontan procedure PAllVS , SIPrnerial switch repair

catheter and sheat looa dilation cath

initial bal~~~ size is E

dilation

an

asty

to

to be 3.5 to 4 times t

relieve branch

the mean age at dilation was 6.6 ?: 6.3 years I month to 38.5 years), with 7 dilations being perr than I year and 6 in patients older

years. A total of 218 stenotic arteries were dilated 155 ~~th~t~ri~atioas~ , The arteries were crouch into four muor is (Table I): tetrnl onnry artery stenoscs (n p‘ ” lesims (n = 471,

The indications for b~l~n

may be dilated at the same ~ath~te~~atio~. In this serie multiple vessels were dilated at the same c~thet~~~tio~ i 47 patients: two vessels in 35 patients, three vessels in Gents and four or ccss is established

to each lung was frequently determined before and after dilation by injecting technetium-99 tagged to macroaggre-

cess

ralc was 61%

ean balloon to ar

compared with the unsuccessful dihions 5.2 I 1.4 atm. respectively. p = 0.31.

0.5

2 1.4 versus

3ACC Vol. 1.5.No. 5 AprilI :llW-117

ROTHMAN ET AL. BALLOON DILATION OF PULMONARY ARTERY STENOSES

lation an~io~~rn.

re. To determine the pressures, ation systolic right ventricular pressures pxcent of systolic nortic pressure) were tknts with an intact interventricular septum or a restrictive ventricular septal defect. systolic right ventricular pressure deceased frs of systemic pressure before dilation to 72 t venttieulw

ry. A 1 year old girl with tetrad y of IFallot M~~erwe~t repair with a traRsa~nular right ve~tricM~~r out ventricular septal defect closure. The :eft p~~rn~~ary artery ~eiat~o~ of patient age (years) to percent increase in pulmonary artery diameter with balloon angioplasly. Regression analysis: y = -0.61~ t 65.9. r = 0.053. p = 0.43.

D

re were four early deaths. Two of 12 patients who underwent dilatbn cause of low cardiac output after cardiac

.

0

5

10

1.5

25

30

35

40

s~r~c~~on and severe bilateral

tension was not unto onary artery

sten

after the procedure abruptly and measured at least twice the diameter of the adjacent pulmonary arter:’ (Fig. 5 and 6). Obviously. because dilation succeeds by tearing the vessel wall, definitions

.

1114

ROTHMAN ET AL. BALLOON DILATION OF PULMONARY

JACC VoQ. 1.5.No. 5

April lW0: 110%19

ARTERY STENOSES

to near predilation size at follow-up, indicating a restenosis rate of 16%. rice. The results and for balloon sngiaplnsty cation rates were corn rieace) and that ~~~~ra~ed performed before 1986(early re 1986,49% of angioplasIn contrast, from 1986 to early 1989,6Q% of procedures were deemed to be successful. The mort~~~ityrate in the early period was 5% (2 of 391. and after 1986 it was ~~~~xirn~tely I% (2 of 1791. The was 13% (5 of 391 b,:fore ence of aneurysm forma and 3% (6 of 1761from I to early 1989.

This review eomprises the largest reported series to date evaluating the results of balloon angioplasty for branch ~lmonary artery stenoses. The success rate of 58% is similar to that previously reported (8). There was no difference in success rate for tetralqy of Fallot, tetralogy of Fallot with resin and isolated ~~ri~her~l ~ulrno~~ry ~lrter~ ontrast, patients in the mbined average S4W. “other” conditions h a higher success rate tients in the latter group had ~ulnlonary either at the site of previous pulmonary or in the area of insertion of an aortopulmosting that surgically induced fibrotic tissue at these stenotic sites is more amenable to balloon dilation than are native lesions. However, stenosis at the insertion site Of an aortopulmonary shunt must be differentiated from

tenting and dist~~io~ of a “nor tension exerted by the shunt (Fig. 71. The served in two patients with ~~s~~~essf~~ plasty, one of w~~~rnunderwent survival divisi early s~~~~~~~~~~~Is e~~~~~~~e

wirlr ti~tr~tl~~~ fitf ~~t~~~? (cspeci mi isolated peripheral pulmo these patients frequently have are less likely to have an increase decrease in right ventricular pre altempt to improve the result tients, we have been dilating catheterization, with no apparent increase in the rate of complications. Age. A previous smaller report (8) suggested a bigher success rate for branch pulmonary artery ao~io~~asty in patients aged e2 years. In this series, there was no correlation between success and patient age at dilation. However, since most pulmonary artery growth occurs before the age of at a 2 years t1S.16). we still recommend ball eters resistively young age. Newer, lower profile have made it possible to perform ~ercMta~eo~s procedures in patients as small as 7 to 8 kg in weight with very low risk of pe~aae~t femoral vein injury. Unusual approaches. Our experience in six patients suggests that pulmonary artery angioplasty can be performed as successfully through an aortopulmonary shunt as through the right ventricular outflow tract. In addition, the percutaneous site for angioplasty does not necessarily have to be

R

ET A&.

~tery di~~~~~~~~~rl~ ik ~~tdt of

. ~rcdi~a~~~~ ~~~i~~~il~~~. a discre1c

waist

~W~~~~~

depicts shtmt j:wrtion site). increase in vessel diameter on the ~~sldi~a~~onangiogra ‘cal division of the shunt, the newly to a warly normal-sized right pulmonary artery.

~~~~w

have successfully

dilated

eon size. Consistent with a larger balloon to artery higher success rate. U of the stenosis was smaller balloons (43% versu balloon size may be I oximal and distal to the stenosis. aneurysms that we encountered. ~o~se~ue~t~y, we currently dilate with an initial balloon larger than three times the diameter of the lesion, ensuring that the distal balloon is inflated in the largest distal pulmonary artery branch.

with larger balloon to artery rattos or highe tion pressures. Aneurys

1116

ROTHMAN ET AL. BALLOON DILATION OF PULMONARY

JACC Vol. IS. No. 5 :1109-I7 April I

ARTERY STENOSES

. Successful balloon ~~~io~~~s~y ~~~~~~~ry artery anastomosis from a ~re~~neous subclavian venous approach. I& The

ofa superior vena cava-right

inflation in this m ion was the cause. consequently. we curmntly take sp2 ial care to advance the wire into the st distal vessel and to avoid very distal balloon inflation. This may be part of the reason for the decrease in incidence of aneurysms after 1986. In addition, because of a high incidenceof aneurysm formation and limited technical control, we now rarely perform intraoperative pulmonary artery balloon dilations. The “natural” histov of these aneurysms is wknown. Ia e aneurysm was found at cathete~zation ioplasty, and the patient died durin surgical attempt to repair the aneurysm. Follow-up of six ysm does not change or of 2 years after angioplasty. he four patients who develary edema were the subject of patients who pulmonary edema with an increase in vessel dia pulmonary artery pressure incensed the risk of appears to be an acute d pulmonary edema was detected on postdilams. The other two patients had symptomatic r dilation and within 72 h of conservative nt had resolution of symptoms and of radioidenee of pulmonary edema. W=UP. The sustained increase in postdilation diameup interval of IQ months (range I to 54

either dilative had caused only a tr~~s~~~t stret~~~ of the vessel or that the ~~~~ess of re

1. Kirklin

JW, Blackstone EH. Kirklin SK. Pa&co AD. Ammendi Bawroa LM Jr. Surgical results and protocols in the spectrum tetralogy of Fallot. Ann Surg 1983;198:251-65.

j, of

2. Baum D. Khoury GH, Ongley PA, Swan HJC. Kincaid OW. Congenital stenosis of the pulmonary artery branches. Circulation 1964;29:68&-7. 3. Mayer SE Jr. Helgason H, Jonas RA. et al. Exlending the limits for modified Fontan procedures. J Thorac Cardiovasc Surg 1986;92:102I-8. 4. McGoon DC. Kincaid OW. Stenosis o sur@cal repair. Med Clin North Am I

of thepulmonary artery: 3-s.

9. Cohn LH. Sanders JH Jr. Collins JJ Jr. Surgical treatment of congenita; unilateral pulr\onq art&at stenosis with contralateral pulmonary hy-

clear predictors of restenosis could tlon diameter, percent increase is diamplasty and age at dilation were not signififor arteries with and withoutrestenosis.The meanfokWup time at which restenosis was detectedwas 4 tmMhs(in tW0 patients as early as 2 months) suggestingthat

pertension. Am J Cardiol 1976:38:257-60. 6. Lock JE. Niemi T. Einzig S. Amplatz K, Burke 5. Bass JL. Transvenous angioplasty of experimental branch p~~rno~~y artery stenosis in ~e~vbor~ lambs. Circulation 1981:61:8&93. 7. Lock JE. Castaneda-Zuniga WR. Fuhrman BP. Bass JL. Balloon dilation angioplasly of hypoplastic and stenotic pulmonary arteries. Circulation 1983:67:%2-7.

Early results and follow-up of balloon angioplasty for branch pulmonary artery stenoses.

Two hundred eighteen balloon angioplasty procedures were performed in 135 patients with branch pulmonary artery stenoses from June 1984 to February 19...
5MB Sizes 0 Downloads 0 Views