Perioperative Anesthetic Considerations for Catheter-Based Pulmonary Vein Interventions in Fibrosing Mediastinitis

Abstract

Introduction: Fibrosing mediastinitis (FM) is a rare disease characterized by abnormal proliferation of fibrous tissue, causing compression and narrowing of the airway, blood vessels, and other mediastinal structures, including the pulmonary veins. Catheter-based interventions are available as palliative strategies. Due to the complex nature of the disease and the profound respiratory and hemodynamic sequelae that may ensue, anesthetic management requires meticulous interdisciplinary planning.

Methods: We performed a retrospective descriptive study including patients with FM undergoing catheter-based interventions for pulmonary vein stenosis from January 2020 to April 2024. A total of 14 patients underwent chart review, and we reported patient sex, preprocedural pulmonary artery pressures, comorbidities, lung isolation strategies, intraprocedural anesthetic complications, postprocedural intensive care unit admissions, and length of stay.

Results: All patients underwent pulmonary vasculature angioplasty, with or without stent placement, under general anesthesia with lung isolation capabilities and echocardiogram guidance. Eleven of 18 (61%) patients were uncomplicated. Four of 18 (22%) patients required unanticipated postoperative intensive care unit care: 2 (11%) in the setting of pulmonary hemorrhage, 1 due to hypoxic respiratory failure, and 1 due to difficult airway. One patient developed self-limiting postoperative hemoptysis on 2 different occasions, and 1 patient developed a vascular access-related complication. Mean hospital length of stay was 2.6 days (0-13 days), and mean intensive care unit length of stay was 1.75 days (1-4 days). One patient presented 6 weeks postoperatively with massive hemoptysis likely secondary to pulmonary vein rupture and died away after a protracted intensive care unit course.

Conclusion: Patients with FM can achieve successful intraprocedural outcomes by ensuring a comprehensive understanding of the disease, addressing significant anesthetic concerns and considerations, and engaging a multidisciplinary team.

Keywords: catheter-based interventions; fibrosing mediastinitis; pulmonary hemorrhage; pulmonary vein stenosis; pulmonary vein stent.