INTRODUCTION:Massive hemorrhage from a lung tumor may lead to exsanguination and asphyxiation. Management often includes localization of the bleeding with subsequent vascular embolization. To protect the contralateral lung, patients may be selectively intubated or ventilated with a double lumen endotracheal tube, but these measures offer only temporary relief. We present a case in which emergent deployment of self-expanding airway stents produced a successful tamponade of massive hemorrhage from a lung tumor , allowing time for follow-up palliative therapy.
CASE PRESENTATION:A 72 year-old female was diagnosed with a left lower-lobe non-small cell lung cancer 17 months prior. Due to underlying COPD and a suspicious contralateral lung nodule, she was not a candidate for surgical resection. She was treated with systemic therapy including six cycles of Carboplatin and Paclitaxel. With disease progression, she underwent second and third line therapy with Erlotinib and Alimta. She did not receive Bevacizumab. She presented to clinic with several weeks of increasing blood tinged sputum, progressing to frank hemoptysis, dyspnea and fatigue. She was admitted with severe anemia (hemoglobin drop from baseline 10 g/Dl to 5.8 (Hct 19.8%)), tachypnea, and tachycardia. A CT scan revealed progression of a LLL cavitary lesion. After overnight transfusion of 3 units PRBC, she underwent a diagnostic bronchoscopy. This revealed continuous blood welling up from the LLL orifice. We were unable to clear the distal left mainstem by suctioning. Urgent interventional radiology evaluation by left-sided intercostal arteriography, thoracic aortography and pulmonary arteriography did not reveal feeding vessels amenable to embolization. Faced with an additional five units blood transfusion to maintain her hematocrit during the day, we repeated bronchoscopy in the OR. After measurement of airway caliber with controlled-radial expansion airway balloons, we deployed two stents in the left-sided airways. The first, a a Polyflex 8mm × 2cm stent, was deployed in the left lower lobe bronchus with deliberate expansion against LLL segmental branches. This yielded transient stoppage of bleeding that provided time to visualize the distal LLL and to attempt packing of the stent lumen with Gelfoam. As the hemorrhage became more brisk, we deployed a covered nitinol Ultraflex 14mm × 6cm stent bridging the proximal left-mainstem across the LLL opening into the LUL bronchus, effectively “jailing” the bleeding site. Thereafter bleeding into the central airway stopped, and fresh blood could be seen pooling behind the semiopaque stent covering. The patient was extubated, with resolution of hemoptysis. After initiation of palliative radiotherapy, she has been stable without further significant bleeding into the central airways in the follow-up two months.
DISCUSSIONS:Massive hemoptysis from non-traumatic causes have a high risk of mortality. Common airway interventions include selective main-stem bronchial intubation; there are occasional reports of successful tamponade by airway balloons. Endovascular stenting for the management of pulmonary hemorrhage due to vascular-bronchial fistulas have been reported. Airway stenting is usually performed for the primary purpose of maintaining airway patency at areas of stenosis, either malignant or benign. Covered airway stents may also be used to cover over pathologic openings such as in tracheo-bronchial-esophageal fistulas. While others have reported that airway stents can occasionally cause massive hemoptysis (through mucosal damage or erosion into major vessels), we believe that this is the first report of the use of self-expanding airway stents to treat a source of pulmonary hemorrhage. This treatment was achieved by both tamponade and the isolation of the bleeding source, so that the proximal large airways were protected.
CONCLUSION:Selective airway stenting with the goal of tamponade and isolation of a pulmonary bleeding source should be considered in the emergency management of massive hemoptysis when interventional vascular embolization and surgical repairs are not immediate options.
DISCLOSURE:Johann Brandes, No Financial Disclosure Information; No Product/Research Disclosure Information