Pulmonary artery perforation due to off-label stent

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This is the case of 13-year-old teenage girl diagnosed with pulmonary atresia with intact ventricular septum treated in the neonatal period with valvulotomy with radiofrequency and percutaneous pulmonary valvuloplasty. Since then, the patient has developed severe pulmonary regurgitation and moderate tricuspid regurgitation. Valve implantation into the right ventricular outflow tract (RVOT) is decided due to worsening functional class with restrictive behavior of the right ventricle (without anticipated dilatation), and hepatic congestion. Cardiac catheterization reveals the presence of a dilated and pulsatile (pulmonary annulus: 29 mm) RVOT with supravalvular stenosis (minimum diameter: 21 mm), and a 34 mm post-stenotic dilatation (figure 1). A second-staged stent is implanted for percutaneous valve implantation. Given the absence of specific material for RVOTs so dilated, a 30 mm x 40 mm self-expandable Sinus-XL stent (Optimed, Germany) (off-label) is selected for being long enough, easy to implant, having enough navigability for the patient’s age (10-Fr sheath), and requiring less radial strength (favorable for dilated RVOTs). Figure 1. A 14-Fr sheath was used to perform position angiographies (figure 1). A few hours later, the patient showed hemodynamic instability with transthoracic echocardiography findings compatible with cardiac tamponade. An emergency computed tomography scan (figure 2) confirmed the perforation of the pulmonary...

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