Percutaneous revascularization of a chronic total occlusion of the left lower pulmonary vein

Pulmonary vein stenosis occurs in 1.3% of patients undergoing pulmonary vein isolation procedures for atrial fibrillation. Complete occlusion can occur and is often associated with symptoms including dyspnea and chest pain. Percutaneous intervention with angioplasty and stenting is frequently performed for pulmonary vein stenosis, but management of pulmonary vein occlusion remains challenging. We report the case of a 47-year-old female who presented with dyspnea and history of two previous radiofrequency ablation procedures for paroxysmal atrial fibrillation. Initial imaging with a ventilation/perfusion scan showed absent perfusion of the lower one-third of the left lung, and occlusion of the left lower pulmonary vein was confirmed by computed tomography (CT). Under sedation, with transesophageal echocardiographic and fluoroscopic guidance, the left atrium was accessed via the right femoral vein and a transseptal puncture. Initially, hydrophilic coronary guidewires were not able to cross the occlusion, but antegrade wire-escalation strategies usually reserved for coronary chronic total occlusion (CTO) cases were successful. The lesion was successfully stented, with prompt resolution of symptoms and stent patency demonstrated at follow-up.