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Successful Closure of a Bronchopleural Fistula With Platinum Vascular Occlusion Coils and N-Butyl-cyanoacrylate Glue

Lahey Clinic, Burlington, MA

INTRODUCTION: The incidence of bronchopleural fistula (BPF) varies from 4.5% to 20% after pneumonectomy and 0.5% after lobectomy (1). Surgical closure has a success rate of 85.7% (2) with associated risks of open thoracotomy. Various materials have been used to attempt endobronchial closure. We report a method of endobronchial closure with vascular occlusion coils and cyanoacrylate glue using flexible bronchoscope and will demonstrate the technique.

CASE PRESENTATION: A 70 year old female with previous history of sarcoidosis presented with massive hemoptysis. Bleeding was initially controlled with embolization of her bronchial artery. She returned in two months with recurrent hemoptysis. After a failed second bronchial artery embolization, a right lower lobe (RLL) resection was performed. Two weeks after surgery she developed persistent pneumothorax that required chest tube placement. Pleurodesis with doxycycline failed. Bronchoscopy revealed a leak in the RLL stump.

Because of high operative risk we decided to close the fistula with an endobronchial approach. A 0.5mm diameter Rapid Transit microcatheter was placed into the stump through the working channel of a flexible bronchoscope. Three 5mm, one 7mm C-TRUFIL and three 3mm complex TRUFIL platinum vascular occlusion coils were propelled into the leaking stump under fluoroscopic guidance.

Two cc of 30% n-butyl-cyanoacrylate (n-BCA) glue was then dripped into the stump around the coils. The air-leak ceased immediately. A chest radiograph revealed complete resolution of pneumothorax and the chest tube was removed. Follow-up bronchoscopy after 5 days revealed solidified glue within the stump.

DISCUSSION: Cyanoacrylate glue has been used during intraoperative stump strengthening after pneumonectomy (34) and is suggested for endobronchial closure of proximal BPF(5). However, use of coils in combination with n-BCA is reported in only three cases(67). N-BCA polymerizes into a solid material upon contact with body fluids or tissue. Iodized oil is added to delay polymerization to about 10-30 seconds. Coils act as a matrix to fix the filling site with glue. The rapid glue solidification mechanically occludes the fistula. Reactive proliferation of bronchial mucosa further contributes to effective closure. Efficacy, safety and lack of toxicity in human use of cyanoacrylate has been demonstrated and n-BCA liquid embolic system is approved by Food and Drug Administraion for embolization of cerebral arteriovenous malformations. Other adhesives such as fibrin, gelfoam, autologous blood patch, coils alone or cyanoacrylate glue alone have been used with variable success.

CONCLUSIONS: Endobronchial closure with vascular occlusion coils and n-butyl-cyanoacrylate glue may be an effective therapeutic option for occlusion of a postresectional BPF in patients with high operative risk. It is safe, non-toxic, relatively non-invasive and inexpensive compared to surgery. Large scale randomized studies are needed to document efficacy.

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REFERENCES

1. Cerfolio RJ, The incidence, etiology and prevention of postresectional bronchopleural fistula.Semin Thorac Cardiovasc Surg13(1)20013 –7
2. Pairolero PC, et al. Postpneumonectomy empyema, The role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg. 1990;99:958–968
3. Eng J, Sabanathan S, Tissue adhesives in bronchial closure. Ann Thorac Surg. 1989;48:683–685
4. Sabanathan S, Richardson J, Management of postpneumonectomy bronchopleural fistula. J Cardiovasc Surg. 1994;35:449–457
5. McManigle JE, et al. Bronchoscopy in the management of bronchopleural fistula. Chest. 1990;97:1235–1238
6. Hirata et al. Endobronchial closure of postoperative bronchopleural fistula using vascular occluding coils and n-butyl-2-cyanoacrylate. Ann Thorac Surg. 2002;74:2174–2175
7. Jain et al. Endobronchial closure of a bronchopleural cutaneous fistula using angiography catheters. AJR. 2000;175:1646–1648

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