Closure of a Bronchopleural Fistula Using an Amplatzer Device Under Fluoroscopic and Bronchoscopic Guidance

Title: Closure of a Bronchopleural Fistula Using an Amplatzer Device Under Fluoroscopic and Bronchoscopic Guidance 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. Clinical Case: A 76 year-old female with hyperlipidemia and a history of bronchioloalveolar carcinoma status-post right upper and right middle lobectomy complicated with BPF and invasive aspergillus pneumonia who presented with worsening dyspnea. She was started on appropriate anti-fungal therapy for aspergillus with voriconazole following diagnosis after initial procedure. However, she continued to report worsening of her dyspnea for the last several months associated with significantly decreased exercise tolerance and productive cough. Computed tomography (CT) scan of the chest revealed a loculated pneumothorax which appeared to communicate with bronchi within the right upper lobe. Bronchoscopy confirmed bronchopleural fistula at the right bronchial stump. She was evaluated by thoracic surgery and deemed to be a poor candidate for surgical closure given her frailty, age, anatomy, and chronicity of the BPF. The patient was presented the option of placing a bronchial stent or implantation of Amplatzer device to close the fistula. She opted for the Amplatzer device. Institutional review board approval was obtained as this is considered off-label and under compassionate humanitarian use of the device. The procedure was done under general anesthesia. Flexible bronchoscopy was performed and the BPF was visualized. The fistula was measure to be 5mm in diameter, as such a 7mm Amplatzer occlude device was chosen. The delivery system was advanced under bronchoscopic and fluoroscopic guidance. The left atrial disc was deployed in the right upper lobe cavity under fluoroscopy. The device was retracted to the bronchial wall and then the right atrial disc was deployed in the right mainstem bronchus under direct bronchoscopic visualization.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 seen to be in good position with rims appearing flush against the bronchial wall. The delivery system and bronchoscope were then retracted and the patient transferred to the recovery area in stable condition. On follow-up, the patient reported significantly improved 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.