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PULMONARY ARTERY STENT SURGERY
Elisabeth Martin, Richard D Mainwaring, Frank L Hanley.
Stanford hospital, Lucille Packard Children's hospital, Stanford, CA, USA.

INTRODUCTION: Peripheral pulmonary artery stenosis poses an extremely challenging management problem. Risks and complications of pulmonary artery stenting are well known: bleeding, reintervention, vessel «jailing», stent embolization, vessel perforation and others. Surgical repair is complex and the presence of stent makes the operation even more technically demanding.METHODS: We present a case of pulmonary atresia, VSD with major aorto-pulmonary collaterals and left bronchial compression. Two previous operations had been performed: RV-PA conduit placement followed by unifocalization, RV-PA conduit replacement and fenestrated VSD closure. The child also underwent 4 catheterizations where 5 stents were implanted. Preoperative investigation revealed RV pressure of 107mmHg with failing RV-PA conduit and bilateral in-stent restenosis. The purpose of this video is to demonstrate our surgical approach to address peripheral pulmonary artery stenosis with failed stenting with a focus on the left pulmonary artery.RESULTS: A median redo-sternotomy was performed and hypothermic cardiopulmonary bypass was established. We performed unifocalization revision of the left lung with extensive reconstruction (2 stent removals, 1 collateral unifocalization, 2 homograft patch augmentations, 6 Heinecke-Miculicz type ostioplasties) followed by unifocalization revision of the right lung. We completed with PFO and VSD closure, conduit replacement and a Lecompte maneuver. Bypass time was 536minutes. The patient tolerated the procedure well with no major complication. Postoperative RV pressure was 30mmHg and RV:aortic pressure ratio was 0.28.CONCLUSION: Surgery can reliably address stenoses and significantly decrease the RV pressure. Surgical repair of PPAS is technically challenging. As demonstrated, this operation is made much more complicated in the presence of stents.


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