Endovascular Stenting for Pulmonary Vein Stenosis Following Atrial Fibrillation Ablation: From Diagnosis to Intervention.

BACKGROUND

Pulmonary vein stenosis (PVS) is an uncommon but serious complication of atrial fibrillation (AF) ablation, often misinterpreted as primary pulmonary disease. Timely identification is essential to prevent irreversible injury and to guide appropriate referral for interventional management.

CASE PRESENTATIONS: Through the discussion of two practical case examples, we illustrate the challenges of early recognition, the role of imaging modalities, and the decision-making process in selecting the most effective interventional strategy. Both young male patients developed progressive dyspnoea, chronic cough, and recurrent pneumonia months after AF ablation and were initially managed for presumed pulmonary pathology. Multimodal imaging-including CT, transoesophageal echocardiography, and selective angiography-confirmed severe multivessel PVS, with a true bifurcation lesion in one case.

MANAGEMENT STRATEGY: The patients were referred for transcatheter pulmonary angioplasty. Procedures were performed under combined fluoroscopic and echocardiographic guidance. In Patient 1, after stenting of the left middle lobar vein in crossover with the left superior pulmonary vein (provisional approach), residual ostial stenosis of the left superior vein required escalation to a culotte bifurcation strategy. Remaining lesions in both patients were treated with large-diameter stents.

CONCLUSIONS AND CLINICAL MANAGEMENT: Early recognition using echocardiography and CT angiography is crucial. Endovascular interventions-particularly stent implantation-provide effective restoration of venous flow, but standardized protocols, long-term patency assessment, and optimal antithrombotic therapy remain areas of ongoing investigation. Advances in coronary intervention may guide refined techniques for managing complex PVS. This paper presents a comprehensive clinical management approach, from symptom onset to definitive treatment.