SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Airway complications are seen in up to one-third of lung transplant patients, most commonly as airway stenosis.[1] An infrequent and extreme form of this is called Vanishing Bronchus Syndrome (VBS). Herein we highlight the challenge of maintaining airway patency in a patient with recurrent multi-segment VBS complicated by diffuse exophytic granulation tissue formation. CASE PRESENTATION: A 61 year-old woman with end-stage COPD due to A1AT-Deficiency presented to an academic quaternary referral center for a bilateral sequential lung transplantation by clamshell thoracotomy. Early post-infectious complications included methicillin-resistant staphylococcus aureus and pseudomonas pneumonia, and candida empyema. Two months post-transplant she returned with progressive respiratory failure requiring mechanical ventilation. Bronchoscopy revealed severe bilateral anastomotic stenosis and malacia, as well as severe non-anastomotic stenosis in all lobes. The right middle lobe could not be visualized. Airway patency was restored using cryo-recanalization, balloon bronchoplasty, contrast bronchography, and placement of several self-expandable metallic stents. This facilitated successful extubation and discharge. One month later she was readmitted with critical re-stenosis of several non-anastomotic airways and obstruction of the lobar stents due to granulation tissue formation. Despite serial balloon dilations and multiple stent revisions the patient continued to experience rapid, recurrent, and extensive airway stenosis. She remains ventilator dependent in the intensive care unit. DISCUSSION: We present a unique case of VBS where our patient had diffuse, bilateral lobar and segmental stenosis with recurrent development of granulation tissue requiring repeated mechanical intervention. Few cases in the literature report such extensive non-anastomotic airway involvement as this case. The pathophysiology of VBS is poorly understood and little is reported about the significance of granulation tissue formation in these cases. We know infections predispose patients to numerous complications, including anastomotic stenosis,[2] but less is known about how the post-transplant microbiome predisposes to the development of VBS. CONCLUSIONS: Literature is lacking about how to best manage Vanishing Bronchus Syndrome. Our future considerations include Mitomycin C, brachytherapy, or photodynamic therapy (PDT) but the efficacy of these modalities is uncertain. Reference #1: Moreno P, Alvarez A, Algar FJ, et al. Incidence, management and clinical outcomes of patients with airway complications following lung transplantation. Eur J Cardiothorac Surg. 2008;34(6):1198-1205. Reference #2: Santacruz JF, Mehta AC. Airway complications and management after lung transplantation: ischemia, dehiscence, and stenosis. Proc Am Thorac Soc. 2009;6(1):79-93. DISCLOSURES: No relevant relationships by Elliot Backer, source=Web Response No relevant relationships by Roy Cho, source=Web Response No relevant relationships by Thomas Meehan, source=Web Response No relevant relationships by Daniel VanDerhoef, source=Web Response