The treatment most often recommended for persistent symptomatic central bronchopleural fistulas (BPF) involves thoracotomy with suture closure and transposition of a vascularized muscle flap or omentum to the bronchial leak site unfortunately, this can be ineffective or medically contraindicated. We used minimally invasive closure techniques including bioadhesives (glues), stainless steel coils and prolene mesh in combination with different imaging techniques to treat recalcitrant central BPF to achieve successful closure in 3 of 5 patients.
We initially (n=2) utilized cyanoacrylate glue injected transthoracically under fluoroscopic guidance into the BPF lumen forming a plug. Next, two patients failed muscle flap transposition and CT guided transthoracic injection of a single coil plus Albumin/Glutaraldehyde glue into the fistula. We then used a transtracheal guidewire positioned under fluoroscopy to identify the fistula and thoracoscopic placement of a prolene mesh patch over the defect secured by fibrin sealant to prevent glue dislodgement. Most recently, stainless steel coils and cyanoacrylate glue were transthoracically injected into and adjacent to a postpneumonectomy bronchial stump under thoracoscopic visualization.
Glue injection under fluoroscopic guidance was successful once while in another, the glue plug was dislodged by coughing. Placing a prolene mesh patch over the BPF secured with fibrin sealant was successful in 1/2 patients. Our most recent effort was to traverse the fistula with coils and inject glue transthoracically. The coils served as a scaffold to stabilize the glue within the tissue and successfully occluded the BPF.
Utilizing these minimally invasive alternative closure techniques, we present the evolution of successful management of recalcitrant central BPFs in 3 of 5 patients. Due to a high intrathoracic to bronchial pressure gradient, one must stabilize the fistula plug. The use of prolene mesh to cover the stump or the injection of coils perpendicularly to the fistula provides a site for inflammation and fibrosis to occlude the fistula.
These image-guided transthoracic techniques provide alternative management for recalcitrant central BPFs in medically compromised patients.
Lindsey Clemson, None.