Severe pulmonary edema after pulmonary hypertension interventional surgery: case report and literature review

Background: Pulmonary hypertension caused by fibrosing mediastinitis often presents with clinical manifestations related to involvement of the pulmonary arteries, pulmonary veins, and bronchi. Interventional therapy has become an important treatment option; however, it carries a significant risk of complications. In this case, the patient developed severe pulmonary edema after intervention, which posed major challenges to clinical management. Case presentation: A middle-aged man presented with recurrent cough, expectoration, chest tightness, and dyspnea. He was initially treated for chronic obstructive pulmonary disease, but his symptoms showed little improvement. Owing to severe pulmonary hypertension, he was referred to the Department of Respiratory Medicine, where right heart catheterization confirmed the diagnosis of fibrosing mediastinitis. He subsequently underwent balloon angioplasty of the left pulmonary artery. During a second admission, he received right pulmonary artery balloon angioplasty with stent implantation under right heart catheter guidance. Shortly after the procedure, he developed severe pulmonary edema complicated by shock and acute renal failure. Conservative treatment was unsuccessful, and veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated. With ECMO support, circulation was stabilized through active fluid resuscitation, followed by careful adjustment of volume status. His pulmonary edema gradually resolved, and he was eventually discharged in full recovery. Conclusion: Pulmonary hypertension caused by fibrosing mediastinitis is associated with poor prognosis. Interventional therapy may improve symptoms and hemodynamics but carries the risk of complications such as pulmonary edema, vascular injury, restenosis, and in-stent thrombosis. In this case, the development of severe pulmonary edema was most likely related to insufficient evaluation of the pulmonary venous system and limitations in the diagnostic and therapeutic process. This emphasizes the importance of comprehensive assessment of pulmonary venous involvement before intervention.