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Endobronchial Closure of Bronchial Pleural Fistula Using a Vascular Plug and Liquid Embolic Agent FREE TO VIEW

Vikas Pathak, MD; Lonny Yarmus, DO; Mark Lessne, MD; Kelvin Hong, MD; Malcolm Brock, MD; David Feller-Kopman, MD; Jason Akulian, MD
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University of North Carolina, Chapel Hill, NC

Chest. 2013;144(4_MeetingAbstracts):35A. doi:10.1378/chest.1702763
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SESSION TITLE: Bronchology Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM

INTRODUCTION: We report the novel use of an Amplatzer Vascular Plug (AVP) in combination with a liquid embolic agent (Onyx®) to seal a chronic BPF.

CASE PRESENTATION: A 66 year old male with a history of adenocarcinoma of the right lung post-pneumonectomy in 2008 and subsequent empyema and BPF presented for BPF endobronchial closure in 2009. Multiple attempts were unsuccessful culminating in an Eloesser flap in 2010. In 2012 the BPF had healed and surgical closure of the flap was performed without complications. Six months later the patient experienced recurrent bronchorrhea with imaging confirming a recurrent BPF. After a multidisciplinary review; given high surgical risk, the decision was made to reattempt endobronchial closure of the BPF. Under rigid bronchoscopy, the right main stem bronchial stump was intubated allowing for passage of a microcatheter to be coiled within the distal stump. Under bronchoscopic and fluoroscopic guidance, an 18mm AVP II® was deployed in the bronchial stump. The stump was then embolized with Onyx-34® liquid embolic through the previously placed microcatheter with care to avoid Onyx® extension above the plug. The patient tolerated the procedure well and was discharged on postoperative day 1 with a marked decrease in respiratory symptoms.

DISCUSSION: The first successful endobronchial management of a BPF using tissue glue and a lead shot was reported in 1977. Since then, many techniques have been employed with varying degrees of success. In our case, endobronchial therapies including cyanoacrylate and SIS® plugs had previously failed resulting in the decision to use an AVP and liquid embolic agent. Onyx® is a non-adhesive liquid embolic agent comprised of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide. These qualities seem to make it an excellent medium for both affixing the AVP as well as filling of the BPF.

CONCLUSIONS: We conclude that AVP when combined with Onyx® is an effective technique to seal BPF. This technique may offer an alternative to patients who are otherwise poor surgical candidates.

Reference #1: Reference: Fruchter, O., et al., Endobronchial closure of bronchopleural fistulas with Amplatzer vascular plug. Eur J Cardiothorac Surg, 2012. 41(1): p. 46-9.

Reference #2: Spiliopoulos, S., et al., Successful exclusion of a large bronchopleural fistula using an Amplatzer II vascular plug and glue embolization. Acta Radiol, 2012. 53(4): p. 406-9.

DISCLOSURE: The following authors have nothing to disclose: Vikas Pathak, Lonny Yarmus, Mark Lessne, Kelvin Hong, Malcolm Brock, David Feller-Kopman, Jason Akulian

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