BPF, a sinus tract between bronchi and the pleural space, occurs as a complication following thoracic surgeries such as lobectomy, thoracotomy, and pulmonary infection [1]. BPFs are associated with high rates of morbidity and mortality with reported mortality ranging as high as 70% [2, 3].

Treatment for BPF ranges from conservative/medical management to bronchoscopic procedures for critically ill patients and surgical intervention for those at the highest risk. There is no consensus as to the best available treatment for the management of such fistulae.

The various surgical options include thoracostomy, thoracoplasty, and direct closure of the fistula using flaps of different origins [4]. Surgery generally carries a dismal prognosis in patients with a poor general condition. Moreover, the recurrence rate of BPF following a surgical repair could be as high as 23.6% [4]. The recurrence rate of BPF following a surgical repair carries a mortality greater than 50%, which is caused by respiratory insufficiency and uncontrolled sepsis [5].

Bronchoscopic management of BPFs is based on the delivery of N- butyl cyanoacrylate glue, coils, emphysema valves, autologous blood patch, AVP, occlusive material to the fistula [1], and tracheobronchial stents [6].

Out of the abovementioned methods, coils, glue, and emphysema valves are preferred for smaller BPFs and are a poor choice for larger fistulas. Larger fistulas provide a poor framework for these occlusive materials and can lead to inadvertent migration of the occlusive material into the pleural space [7,8,9].

Blood patches have been used for the management of BPFs with poor outcome rates ranging from 27-72%. The shortcomings of blood patch for the management of BPFs include the risk of pleural infection. Also, complete closure of fistulas using blood patches required multiple bronchoscopy sessions with closure rates following the first session being as low as 56% [10].

Management of BPF using different types of stents has been described. Stents can however lead to sputum retention by impeding mucociliary clearance [7]. Also, stents were not available at our institution at the time of this case.

Amplatzer plugs have been used for the management of congenital septal defects [11], pulmonary arteriovenous malformations, anomalous venous connections, and internal iliac arteries [12, 13].

AVPs have been successfully used for the management of BPFs with no recurrent disease in almost all previously described studies (Table 1).

Table 1 Previous studies on the management of BPFs using plug devices

AVP are a good choice for BPFs which are long and wide such as the one in this case.

AVP devices are made of two discs with a central waist made of a mesh of braided nitinol. The central waist measures from 4 to 40 mm in diameter. The distal disc is about 14mm and the proximal disc is 10 mm larger, respectively, than the diameter of the central waist. This provides an anchoring lip of about 5–7 mm circumferentially.

The waist is positioned inside the defect, while the discs anchor the device on either side of the fistula. AVP devices can be collapsed into low-profile delivery sheaths (5–7 French) owing to the superelastic and shape memory properties of nitinol. This allows the advancement of the devices across the lesion [8].

The plug is attached to a 155-cm-long delivery wire with a micro screw made of stainless steel, allowing the operator to release the plug into the final position by rotating the cable using a supplied torque device. The plug can be readjusted and retrieved as needed before it is finally released. The AVP is compatible with magnetic resonance imaging (MRI), within a magnetic field of less than 3 Tesla [23].

They are designed to provide immediate effective closure of the defect, are available in a large range of sizes, and can be appropriately matched to the lesion. The presence of two disks, one on either side of the lesion, leads to greater coverage and increases the likelihood of closure, as opposed to glue, which is applied to the internal aspect alone.

The devices induce endothelial response and potentiating granulation tissue without causing airway compromise which eventually leads to closure of the fistula [13, 24].

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