Case report: Endobronchial closure of postoperative bronchopleural fistula with embolization coil: a sandwich-like approach

Abstract

Background: Embolization Coil has been reported to effectively treat postoperative bronchopleural fistula (BPF). Little detailed information was available on computer tomography (CT) imaging features of postoperative BPF and treating procedures with pushable Embolization Coil.

Objective: We aimed to specify the imaging characteristics of postoperative BPFs and present our experience treating them with the pushable Embolization Coil.

Methods: Six consecutive patients (four males and two females aged 29-56 years) diagnosed with postoperative BPF receiving bronchoscopic treatment with the pushable Nester® Embolization Coil (Cook Medical, Bloomington, Indiana) were included in this single-center, retrospective study. Multiplanar reconstruction of multidetector CT scans was reviewed for the presence, location, size, and radiological complications of each BPF, including air collection, pneumothorax, bronchiectasis, and chest tube. Using standardized data abstraction forms, demographic traits and clinical outcomes were extracted from the medical files of these patients.

Results: The underlying diseases for lung resection surgery were pulmonary tuberculosis (n = 3), lung adenocarcinoma (n = 2), and pulmonary aspergillosis (n = 1). All patients had air or air-fluid collection with chest tubes on radiological findings. Multiplanar reconstruction identified the presence of postoperative BPF in all patients. Five fistulas were central, located proximal to the main or lobar bronchus, while one was peripheral, distant from the lobar bronchus. Fistula sizes ranged from 0.8 to 5.8 mm. Subsequent bronchoscopy and occlusion testing confirmed fistula openings in the bronchial stump: right main bronchus (n = 1), right upper lobe (n = 2), and left upper lobe (n = 3). The angioplasty catheter-based procedure allows precise fistula occlusion "like a sandwich" with the pushable Embolization Coil. Five patients with BPF sizes ranging from 0.8 to 1.5 mm were successfully treated with a pushable Embolization Coil, except for one with a BPF size of 5.8 mm. No adverse events or complications were observed throughout follow-up, ranging from 29 to 1,307 days.

Conclusion: The pushable Nester® Embolization Coil seems a minimally invasive, cost-effective, and relatively easy-to-perform bronchoscopic treatment for postoperative BPF with a size less than 2 mm. Further studies are required to ensure the use of pushable Embolization Coil in treating postoperative BPF.

Keywords: Embolization Coil; bronchopleural fistula; bronchoscopic treatment; case series; interventional pulmonary.

Figure 1

The detailed procedures in treating the postoperative bronchopleural fistula with a pushable Embolization Coil. (A) The bronchoscopy found the anastomotic nails and suspected fistula opening (black arrow) in the bronchial stump of the left upper lobe (intrinsic branch). (B) Forceps occlusion testing confirmed the fistula opening in the intrinsic branch, stopping the air leak from the chest tube. (C) The first half of a pushable Embolization Coil was delivered into the fistula opening via a 5 Fr angioplasty catheter (black arrow). (D) The transbronchial insertion of the pushable Embolization Coil successfully occluded the fistula opening, with the other half deployed proximal to the segmental branch. (E,F) The schema and chest computed tomography illustrated how the fistula tract was surrounded by the coil’s curves (black arrow) and well-balanced on both fistula openings “like a sandwich”.

Figure 2

A 44-year-old woman with persistent air leak after left upper lobectomy for lung adenocarcinoma in situ received the treatment of a single pushable Embolization Coil. (A,B) Chest computed tomography (CT) scans (axial and sagittal planes) demonstrated compressive atelectasis (blue asterisk) and pneumothorax in the left lung, which communicated directly (black arrows) with the bronchial stump. (C,D) Follow-up CT scans (axial and coronal planes) obtained 1 month after treatment demonstrated the complete closure of the fistula tract by the curved Embolization Coil which formed a tight occluding mass “like a sandwich” (black arrows), resolving the pneumothorax with the expansion of the collapsed lung tissue.