Late-onset bilateral pulmonary vein stenosis after living-donor lobar lung transplantation managed with balloon angioplasty: a case report.

Background: Pulmonary vein stenosis (PVS) is a rare but potentially life-threatening complication after lung transplantation. Most reported cases occur during the early postoperative period and are associated with technical issues at the venous anastomosis. Late-onset PVS is extremely uncommon and may be overlooked because its clinical presentation mimics infection, rejection, or chronic lung allograft dysfunction (CLAD). Case Description: A woman in her 20s with familial interstitial pneumonia underwent living-donor lobar lung transplantation (LDLLT). Her postoperative course was uneventful, and graft function remained stable for 2 years. She subsequently developed progressive dyspnea, hypoxemia, and massive pleural effusion. Computed tomography (CT) angiography demonstrated bilateral PVS at the venous anastomotic sites. Right heart catheterization revealed significant diastolic pressure gradients between pulmonary artery wedge pressure and left atrial pressure, confirming physiologically significant PVS. Transseptal balloon angioplasty was successfully performed for both pulmonary veins. Mean pulmonary arterial pressure decreased immediately from 66 to 35 mmHg, and pulmonary vein flow velocities on Doppler echocardiography improved substantially. Follow-up catheterization demonstrated near-complete resolution of the pressure gradients. The patient recovered rapidly and remained asymptomatic without restenosis at 12-month follow-up. Conclusions: Late-onset bilateral PVS after LDLLT is extremely rare but may result in severe cardiopulmonary deterioration. Because the clinical manifestations are nonspecific, delayed diagnosis may occur. Balloon angioplasty may provide favorable short-term clinical and hemodynamic improvement in selected patients.