Chronic Total Occlusion Techniques to Recanalize an Occluded Pulmonary Vein After Atrial Fibrillation Ablation

Keywords: chronic total occlusion, left inferior pulmonary vein

A 69-year-old male with atrial fibrillation radiofrequency ablation 2 years ago was admitted for transcatheter angioplasty of left inferior pulmonary vein (LIPV) stenosis due to recurrent hemoptysis. A cardiac computed tomography (CT) scan was performed showing complete ostial occlusion in the area of the LIPV (Figure 1A). Pigtail angiography through the transseptal sheath was made without visualizing the ostium of LIPV branch (Figure 1B). A brief attempt to cross over with a Mariner and Tacticath catheter (Angiodynamics) was unsuccessful due to difficulty identifying the LIPV ostium. We advanced a Berman catheter (Teleflex) through the contralateral femoral vein and positioned it in a lower branch of the left pulmonary artery. Angiography was performed, visualizing LIPV retrogradely and identifying a short ostial occlusion (Figure 1C). Guided by retrograde injection, the Tacticath was positioned on the LIPV ostium and the occlusion was crossed (Figure 1D). A high-support .035˝ guidewire was advanced into the LIPV and predilated with a 6-mm balloon. The guidewire was exchanged for an angioplasty guidewire and intravascular ultrasound (IVUS) was performed to measure the reference luminal diameter of the vessel distal to the occlusion (Figure 1E). A 9- x 18-mm Restorer stent (iVascular) was implanted. Due to the clear under-expansion, postdilation of the ostium was performed with the stent-balloon at 16 atm with excellent results (Figure 1F and Video 1). The patient was discharged without complications.

Occlusion of the pulmonary vein ostium is a rare complication. The use of chronic occlusion techniques is exceptional for the approach of these cases. However, it is a common technique for chronic total occlusion operators.

Affiliations and Disclosures

From the Cardiology Department, La Paz University Hospital, Madrid, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 21, 2022.

Address for correspondence: Alfonso Jurado-Roman, MD, PhD, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain. Email: alfonsojuradoroman@gmail.com