Conservative management of iatrogenic pulmonary vein obstruction following transcatheter sinus venosus ASD repair: a case insight and literature review.

BACKGROUND: Iatrogenic pulmonary vein obstruction (PVO) is a rare but serious complication that may occur following transcatheter correction of sinus venosus atrial septal defect (SVASD) with partial anomalous pulmonary venous connection (PAPVC) using covered stents. This procedure has gained increasing acceptance in recent years. The optimal management strategy, particularly the role of conservative therapy, remains poorly defined. A 42-year-old man with a 1.5 × 1.0 cm superior vena cava (SVC)-type SVASD, PAPVC, and severe pulmonary arterial hypertension (PAH) underwent transcatheter repair after six months of targeted vasodilator therapy. Under fluoroscopic and transesophageal echocardiographic (TEE) guidance, a 57 mm long Optimus-CVS PTFE-covered XXL stent (AndraTec, Germany) was deployed, internally telescoped with a 45 mm long bare-metal CP stent (NuMED, USA) for cranial anchoring. Intra-procedural TEE showed correct stent position and unobstructed pulmonary venous flow. However, 24 h later, the patient developed acute hypoxemia. Computed tomography angiography revealed complete occlusion of the anterior segment of the right upper pulmonary vein with associated thrombosis. Because the patient remained hemodynamically stable, conservative management was initiated with corticosteroids, diuretics, and therapeutic anticoagulation (apixaban plus aspirin). Within five days, oxygen saturation normalized to 90% on room air, and chest imaging confirmed resolution of pulmonary infiltrates. Follow-up at six months showed a stable stent position and no residual obstruction.

CONCLUSION: PVO following transcatheter SVASD repair may not be diagnosed immediately after stent deployment, as it can present with delayed onset due to progressive thrombosis formation. Normal intra-procedural imaging does not exclude subsequent PVO, and vigilant post-procedural monitoring is essential. In carefully selected, hemodynamically stable patients, conservative management with corticosteroids, anticoagulation, and diuretics can lead to complete clinical and radiographic recovery, restoring pulmonary venous drainage and potentially avoiding reintervention or surgery.