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Case Report

Focal Pulmonary Edema: A Complication of Endovascular

Stent Dilatation of Pulmonary Artery Stenoses
Jeremy J. Erasmus1and Philip C. Goodman

Peripheral pulmonary artery stenosis may be found as an excluded thrombosis of the pulmonary stents and pulmonary artery
isolated abnormality on may occur in patients with complex emboli. No clinical or laboratory evidence of pneumonia was

congenital heart disease. Serious consequences of this observed. The patient improved on acetaminophen and 100% oxy-
abnormality frequently lead to treatment. Intravascular stents gen delivered by face mask, and a follow-up chest radiograph on
day 7 after the procedure showed significant improvement of the
have been used with increasing frequency in the manage-
opacities in the right lower lobe (Fig. 1C).
ment of these patients. A potential complication of successful
pulmonary artery dilatation and endovascular stent place-
ment is focal pulmonary edema. This complication is pre- Discussion
sumed to be due to an acute increase in local pulmonary
blood flow, occurs early in the postoperative period, and Surgical revision of pulmonary artery stenoses is usually
resolves rapidly. unsuccessful [1], and balloon angioplasty of these stenoses
We reviewed the chest nadiognaphs and radionuclide lung is successful in only 58% of cases, with late nestenosis
scans in two patients who had focal lung opacities after occurring in 1 6% [2, 3]. This high rate of failure may be asso-
placement of a stent in the pulmonary artery. ciated with inherent elastic recoil of the pulmonary arteries
combined with scanning on early myointimal hypenplasia after
dilatation [4].
Case Report Expandable stents were first described by Palmaz et al. in
A 40-year-old man with previously repaired aortic stenosis and a 1985 [5]. They have been effective in maintaining vessel
ventricular septal defect had pulmonary arterial hypertension due to patency in both peripheral and coronary artery stenoses.
multiple, bilateral secondary and tertiary pulmonary artery stenoses More recently, stents have been used in the treatment of
and presented with mild-effort dyspnea. At surgery, endovascular stenoses in patients with congenital heart disease [4]. These
Johnson & Johnson (Warren, NJ) Palmaz stents were successfully stents have been used to dilate stenoses in the pulmonary
inserted in three stenosed pulmonary arteries in the right lower lobe. arteries, systemic veins, night atrium, and night ventricular
Two of the stents were 20 mm in length, with an outside diameter of
conduits [6]. In limited clinical studies, these stents appear to
2.5 mm, and one stent was 30 mm in length, with an outside diameter
maintain patency with no late side effects of thrombosis,
of 3.4 mm. No immediate complications occurred, and right ventricu-
Ian pressure decreased from 120/12 mm Hg to 70/50 mm Hg.
embolus, on infection [4, 7].
On the second postoperative day, the patient had acute dyspnea, Endovasculan stents may be inserted surgically or pencuta-
chest pain, and hypoxia. A chest radiograph showed opacities in the neously. The latter approach uses a stainless steel, balloon-
right lower lobe (Fig. 1A), with increased perfusion in that region expandable endovascular stent mounted onto a balloon
seen on the radionuclide scan (Fig. 1B). Pulmonary angiography angioplasty catheter. The diameter of the stent is determined

Received March 7, 1 995: accepted after revision May 15, 1995.

1 Both authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Address correspondence to J. J. Erasmus.

AJR 1995;165:821-823 0361-803)(/95/1654-821 © American Roentgen Ray Society

 822 ERASMUS AND GOODMAN AJR:165, October 1995

4D
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B C
Fig. 1.-Focal pulmonary edema. 40-year-old man who had three Palmaz stents in stenosed right lower lobe pulmonary arteries.
A, Anteroposterior chest radiograph shows diffuse homogeneous opacification involving right lower lobe, cardiomegaly, and three endovascular
stents in right pulmonary artery.
B, Technetium radionuclide perfusion scan shows increased perfusion of right lower lobe. Perfusion of remaining right and left lung is decreased.
C, Chest radiograph shows marked resolution of opacities in right lower lobe. Central enlargement of pulmonary arteries and stents in right pulmo-
nary artery are unchanged in appearance from A.

A B C
Fig. 2.-Focal pulmonary edema. 23-year-old man with Williams syndrome (supravalvular aortlc stenosis, mental retardation, and elfin facies) and
severe, bilateral stenoses of secondary and tertiary pulmonary arteries.
A, Posteroanterior chest radiograph shows no focal lung abnormality, but mild cardiomegaly and scoliosis are present.
B, Posteroanterior radiograph shows diffuse homogeneous opacification involving basal segments of right lower lobe 1 day following Palmaz endo-
vascular stent placement in right lower lobe pulmonary artery. Patient was afebrile and had mild dyspnea.
C, Chest radiograph 3 days after diuretic therapy shows marked improvement in opacity.

by the size and length of the stenotic area and the desired knowledge has not been reported in patients after stent
postoperative diameter [4]. The stent-balloon complex is placement. In a retrospective review by Arnold et al. [8], tran-
positioned across the stenosis, the balloon inflated, and the sient focal edema occurred in 4 of 63 patients who under-
stent implanted. Complications including ventricular arrhyth- went a total of 65 balloon dilatations. With balloon dilatation,
mias, thrombus formation, compromise of pulmonary artery an increase in distal pulmonary arterial pressure or vessel
side branches, intimal flaps, and pulmonary artery rupture diameter of more than 170% and 70%, respectively, or a
have been reported [4]. Misplacement and migration of mean distal pressure greater than 20 mm Hg is associated
stents occurs infrequently [7]. Improved selection of patients with a higher risk of pulmonary edema [8]. The mechanism
and refinement of catheterization and stent placement tech- appears to be an acute increase in capillary perfusion pres-
nique have reduced the frequency of these complications [4]. sure [1 8] and is presumed
, to be the cause of focal pulmo-
Transient pulmonary edema has occurred after balloon nary edema in our two patients. Both of our patients had
angioplasty of pulmonary artery stenoses [1 8] but to our
, homogeneous opacities on chest radiographs in lung per-
 AJR:165, October 1995 FOCAL PULMONARY EDEMA 823

fused by the dilated and stented pulmonary arteries. The emboli and stent thrombosis and offers an alternative diag-
absence of a focal opacity in the right upper lobe in our sec- nosis to pneumonia, infarction, or hemorrhage.
ond patient, after dilatation of an upper lobe pulmonary
artery stenosis without stent placement, is presumed to have
REFERENCES
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after the procedure (Fig. 2). Based on the evolution of clinical 1. Rothman A, Perry SB, Keane JF, Locke JE. Early results and follow-up of
balloon angioplasty for branch pulmonary artery stenosis. J Am Coil Car-
Downloaded from www.ajronline.org by 110.137.98.192 on 03/15/18 from IP address 110.137.98.192. Copyright ARRS. For personal use only; all rights reserved

and radiographic findings, and in one patient nadionuclide

dioll99O:15:1109-1117
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In conclusion, ipsilatenal focal pulmonary edema, a necog-
6. Schlesinger AE, Caoili EM, Mendelsohn AM, Bove EL, Beekman RH.
nized complication of balloon dilatation of pulmonary artery Radiography of thoracic intravascular stents in children with congenital
stenoses, may also be seen with endovasculan stent place- heart disease. Pediatr Radiol I 993:23:113-116
ment. As endovasculan stenting becomes more widely used 7. Hosking MC, Benson LN, Nakanishi T, Burrows PE, Williams WG, Free-
in the management of patients with pulmonary artery dom RM. Intravascular stent prosthesis for right ventricular outflow
obstruction. JAm Coil Cardiol 1992:20:373-380
stenoses, focal pulmonary edema may be encountered more 8. Arnold LW, Keane JF, Kan JS, et al. Transient unilateral pulmonary edema
frequently. Knowledge of this radiographic observation after successful balloon dilatation of peripheral pulmonary artery steno-
should curtail unnecessary imaging to exclude pulmonary sis. Am J Cardiol 1988:62:327-330