CLOSURE OF A BRONCHOPLEURAL FISTUAL USING AN AMPLATZER DEVICE UNDER FLUOROSCOPIC AND BRONCHOSCOPIC GUIDANCE

Abstract

SESSION TITLE: Case Report Semifinalists 4 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Bronchopleural fistula (BPF) is a rare complication with potentially fatal consequences following pulmonary resection. Incidence has been reported at 0.5% following lobectomy and is more prevalent in patients undergoing resection for malignant versus benign conditions. Correction of BPF is accomplished utilizing surgical and endoscopic techniques. Here, we describe an endobronchial closure of a BPF using an Amplatzer device in a patient who was deemed a poor surgical candidate. CASE PRESENTATION: A 76 year-old female with history of bronchioloalveolar carcinoma status-post right upper and right middle lobectomy complicated by BPF and invasive aspergillus pneumonia who presented with worsening dyspnea. She was treated with anti-fungal therapy for aspergillus. However despite appropriate treatment, her dyspnea worsened with associated productive cough. Computed tomography (CT) of the chest revealed a loculated pneumothorax which communicated with the bronchus stump and a 5mm bronchopleural fistula. Thoracic surgery evaluation deemed her to be a poor candidate for surgical closure given her frailty, age, anatomy, and chronicity of the BPF. Institutional review board approved the off-label and compassionate humanitarian use of the Amplatzer ASD occluder device. The procedure was done under general anesthesia. A 7mm device was chosen. After general anesthesia, a rigid bronchoscope was introduced into the trachea. Through this, a flexible bronchoscope was advanced to the right bronchus and the fistula visualized. A Jag wire was advanced into the pleural cavity via the BPF and position confirmed by fluoroscopy. The 7F delivery catheter and delivery system was prepared and the ASD closure device loaded. Delivery catheter was advanced into the pleural space over the wire. The left atrial disc was deployed in the right upper lobe pleural cavity under fluoroscopy. The disc was retracted to the bronchial wall and then the right atrial disc was deployed in the right mainstem bronchus under direct bronchoscopic visualization. The device was released after it was seen to be in good position with rims appearing flush against the bronchial wall. The patient tolerated the procedure well. At follow-up, the patient reported significant improvement in symptoms and exercise tolerance. Repeat bronchoscopy revealed a small air leak that is currently being monitored. DISCUSSION: Postoperative complication following pulmonary resection is the most common etiology of BPF. As these patients may be particularly frail and poor surgical candidates it is important to present all available therapeutic options. We described a case of BPF closure using an Amplatzer device with good results. Further studies should be performed to assess true safety and efficacy. CONCLUSIONS: Amplatzer occluder devices may be a viable option to correct BPF in patients who are poor candidates for surgical correction. Reference #1: Cerfolio, Robert James. “The Incidence, Etiology, and Prevention of Postresectional Bronchopleural Fistula.” Seminars in Thoracic and Cardiovascular Surgery, vol. 13, no. 1, Jan. 2001, pp. 3–7 Reference #2: Lois, Manuel, and Marc Noppen. “Bronchopleural Fistulas: An Overview of the Problem With Special Focus on Endoscopic Management.” Chest, vol. 128, no. 6, Dec. 2005, pp. 3955–65. Reference #3: Endobronchial closure of bronchopleural fistula using Amplatzer device. J Thorac Dis. 2015 Aug; 7(8): 1478–1482. DISCLOSURES: No relevant relationships by Amarbir Bhullar, source=Web Response no disclosure on file for Pravachan Hegde; no disclosure on file for Elliot Ho; No relevant relationships by Kassra Poosti, source=Web Response No relevant relationships by Chirag Rajyaguru, source=Web Response No relevant relationships by Uday Sandhu, source=Web Response no disclosure on file for Rohit Srivastava