SESSION TITLE: Airway Cases II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM
INTRODUCTION: Airway stabilization for severe symptomatic tracheobronchomalacia (TBM) may be accomplished by silicone Y-stent placement. Complications of the stent may include mucus plugging and the formation of granulation tissue. We describe management of a very rare case of pulsatile, life-threatening hemoptysis originating from the distal left mainstem bronchus adjacent to the bronchial limb of a Y-stent placed for TBM.
CASE PRESENTATION: A 65 year-old female presented to the ICU with massive hemoptysis 3 months after placement of a Y-stent for symptomatic TBM in which tracheobronchoplasty was not a viable treatment option. One month prior to her hemoptysis presentation, she underwent argon plasma coagulation (APC) to ablate granulation tissue. Following intubation, the bleeding source was bronchoscopically localized to the distal left mainstem bronchus and an endobronchial blocker was placed to stabilize the patient. She urgently underwent removal of the Y stent and a pulsatile vessel was identified as the bleeding source. This vessel was visualized just beyond the bronchial limb of the Y-stent in the distal left mainstem bronchus, proximal to the left hilum. Its pulsatile nature and location suggested an arterial source. Placement of oxidized cellulose (Surgicel, Ethicon) controlled the bleeding. Using two ureteral catheters tied in tandem, a synthetic sealant (CoSeal, Baxter) was then administered endobronchially at the site of bleeding. Placement of these catheters distally in the left mainstem enabled endobronchial mixing of the sealant for direct application at the bleeding site. She had no further hemoptysis, and follow-up bronchoscopy 3 weeks later demonstrated mucosal healing.
DISCUSSION: In the few cases of hemoptysis following Y-stent placement, the proposed mechanism is either local erosion or fistula formation.1In this case of pulsatile hemoptysis due to bleeding from an arterial source, we hypothesized that the oxidized cellulose provided sufficient hemostasis and the subsequent synthetic polymer (CoSeal) reinforced the tissue for complete cessation of the bleed. Removal of the stent minimized the risk of recurrent bleeding.
CONCLUSIONS: Massive hemoptysis complicating Y stent placement is rare. In addition to minimizing ongoing injury, a combination of endobronchial oxidized cellulose and a synthetic polymer provided long-term management for this potential life-threatening problem. Potentially morbid procedures such as embolization or surgery were avoided by advanced endobronchial therapy.
Reference #1: Oki, M and Saka, H. New Dedicated Bifurcated Silicone Stent Placement for Stenosis Around the Primary Right Carina. Chest. 2013 Mar 7. doi: 10.1378/chest.12-2834.
DISCLOSURE: The following authors have nothing to disclose: Changwan Ryu, Kyle Bramley, Daniel Boffa, Margaret Pisani, Jonathan Puchalski
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