Percutaneous Vascular Stent Implantation as Treatment for Central Vascular Obstruction Due to Fibrosing Mediastinitis

Abstract

Background Fibrosing Mediastinitis (FM) is a rare complication of infection with Histoplasma capsulatum, which can lead to obstruction of pulmonary and systemic vasculature and large airways, often resulting in significant morbidity and mortality. Medical therapy is ineffective and surgical intervention is often not feasible. Stent implantation offers a potential treatment for vascular obstruction due to FM, but this has not been well studied. Methods and Results We conducted a retrospective review of all patients undergoing cardiac catheterization for FM. Anatomic site of stenosis and hemodynamic information before and after intervention, as well as clinical presentation and follow-up data were recorded. From 1996 to 2008, 58 patients underwent cardiac catheterization for FM, with intervention performed in 40 (69%). A total of 77 stents were used to relieve 59 lesions (pulmonary artery = 26, pulmonary vein = 21, superior vena cava = 12). Significant reduction in pressure gradients (p<0.001) and increase in vessel caliber (p<0.001) was seen at all locations. Symptomatic recurrent stenosis requiring further intervention occurred in 11 (28%) patients. Median time to recurrence was 115 months. Thirty-two (87%) of 37 patients for whom follow-up was available reported symptomatic improvement following stent placement. Procedure-related complications occurred in 14 patients (24%). Overall mortality was 19%, with the majority of deaths in patients with bilateral disease. Among patients with bilateral disease, intervention was associated with improved survival at 5 years. Conclusions Percutaneous vascular stent implantation is an effective therapy for central vascular obstruction due to FM, providing significant relief of anatomic obstruction and sustained clinical improvement.

Targeting B Lymphocytes in Progressive Fibrosing Mediastinitis

“…Although anecdotal success with antifungal, antiinflammatory, and antifibrotic therapy has been reported (5,6), these results have not been confirmed in larger cases series (4). Furthermore, the success of surgical and nonsurgical interventions to relieve invasive vascular and airway obstruction has been variable, ranging from complete recovery to therapeutic failure with procedural mortality (4,5,(7)(8)(9)(10). New therapeutic approaches are urgently needed.…”

Fibrosing Mediastinitis

“…12 These scans help localize the involved lung segments, provide functional information about the overall impairment in either ventilation or perfusion, and provide estimates of the potential benefits with vascular and bronchial procedures to open up compressed structures. 18,19,20 Pulmonary angiography can detect pulmonary arterial obstruction, and venography provides for the diagnosis of SVC syndrome or proximal SVC occlusion. Pulmonary function results depend on the type and extent of occlusion and provide an overall assessment of ventilatory impairment.…”

“…20 Non-surgical interventions, such as balloon angioplasty with intravascular stenting, are effective in the management of vascular compression and provide symptomatic relief in up to 87% of patients (Table 2). 23 The procedure may be difficult due to a higher pressure requirement for the deployment of the stent in compressed vessels and due to a tendency for stents to migrate into a non-involved area of the vessel. The need for restenting secondary to progressive fibrous tissue growth, thrombosis, or stent collapse has been reported in up to 28% of cases with a median time to recurrence of 115 months.…”

“…The need for restenting secondary to progressive fibrous tissue growth, thrombosis, or stent collapse has been reported in up to 28% of cases with a median time to recurrence of 115 months. 23 Albers concluded that percutaneous interventions improved clinical outcomes and the five year survival rate in cases with bilateral but not unilateral vascular occlusion. 23 Bronchial stents can open up compressed airways.…”

“…23 Albers concluded that percutaneous interventions improved clinical outcomes and the five year survival rate in cases with bilateral but not unilateral vascular occlusion. 23 Bronchial stents can open up compressed airways. Surgical vascular reconstruction techniques with bypass grafting using silicone prostheses, homografts, or saphenous vein grafts should be considered as an alternative to stenting, especially in younger patients and in patients with unsuccessful percutaneous interventions.…”