Closure of Chronic Bronchopleural Fistula Using Atrial Septal Occluder Device Vikas Marwah, MD (Resp Med), Ashok Kumar Rajput, MD (Med), MD (RespMed), DNB, Heman Madan, DM (Cardiology), MD (Med), and Yadvir Garg, MD (Resp Med)

Summary: Chronic persistent bronchopleural fistulae

(BPF) are challenging management problems. The management of BPF includes various surgical and medical procedures and of great value is the use of bronchoscopy and different devices. In high-risk surgical patients, bronchoscopic procedures serve as a temporary bridge until the patient’s clinical condition improves, whereas in other patients bronchoscopic procedures may be the only option. We present a case of postoperative chronic BPF closed by a less invasive interventional bronchoscopic procedure using an atrial septal occluder device. Key Words: device closure of BPF, postoperative large central BPF, septal occluder device (J Bronchol Intervent Pulmonol 2014;21:82–84)


ostpneumonectomy bronchopleural fistulae (BPF) are challenging management problems and are associated with high morbidity and mortality. Traditionally, BPF have been closed with primary surgery or delayed closure with open-window thoracostomy with or without omental or muscle flap reinforcement. The closure of BPF depends upon its size, location, as well as its time course in relation to surgery. In high-risk surgical patients, bronchoscopic procedures serve as a temporary bridge until the patient’s clinical condition improves, whereas in patients who fail surgical closure, bronchoscopic procedures may be the only option. Bronchoscopic closure has been described with various bioadhesives and devices. We describe another case in which large chronic postoperative BPF was closed with an atrial septal occluder device.

Received for publication April 15, 2013; accepted November 13, 2013. From the Department of Respiratory Medicine, Army Hospital (Research & Referral), Delhi Cantt, New Delhi, India. Disclosure: There is no conflict of interest or other disclosures. Reprints: Vikas Marwah, MD (Resp Med), Department of Respiratory Medicine, Army Hospital (R&R), Delhi Cantt-10, New Delhi, India (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins

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CASE REPORT A 65-year-old man with a history of posttuberculous bronchiectasis involving right upper lobe developed recurrent hemoptysis, which did not respond to conservative measures and bronchial artery embolization. He was subjected to right upper lobe (RUL) lobectomy in 2005, following which he had hemorrhagic shock and was reexplored and underwent completion of the pneumonectomy. He developed postoperative bronchopleural fistula for which surgical closure was attempted along with creation of modified Eloesser flap for drainage of empyema in 2006. Despite repeat surgery and closure of fistula, the broncho-pleuro-cutaneous fistula persisted (Fig. 1). He presented with discharging wound involving right axillary region along with bubbling from the wound and breathlessness on exertion. Chest radiograph revealed an air fluid level in addition to findings of previous thoracoplasty. Flexible bronchoscopy revealed a large fistula at site of right bronchial stump (Fig. 2). Spirometry revealed moderate restrictive defect. Computed tomogram of the chest revealed an 11.4 mm fistula at the bronchial stump communicating with the pleural cavity with a cutaneous opening. The patient was unwilling for another surgery for closure of the fistula. In view of persistent chronic postoperative BPF, its bronchoscopic closure using atrial septal occluder device used

FIGURE 1. The cutaneous aspect of large bronchopleuro-cutaneous fistula.

J Bronchol Intervent Pulmonol

Volume 21, Number 1, January 2014

J Bronchol Intervent Pulmonol

Volume 21, Number 1, January 2014

Closure of Chronic BPF Using Atrial Septal Occluder Device

FIGURE 2. Bronchopleural fistulae (arrows) at right main bronchial stump before and after the device closure.

for closure of atrial septal defects by cardiologists was considered. A guidewire was passed through the working channel of the bronchoscope into the fistula and was then delivered through the cutaneous wound. The sheath of the device was passed over the guidewire which was positioned into the fistula. A 14 mm septal occluder device (Lifetech, Shenzhen, P.R. China) (Fig. 3) was placed inside the sheath and deployed transcutaneously over the fistula under bronchoscopic control. The outer (distal) portion of the disk was deployed successfully in the pleural cavity. The fistula was thus covered completely with the device (Fig. 4), and the discharge from the wound reduced significantly thereafter. The patient was placed on prophylactic parenteral antibiotics. Four weeks later, repeat flexible bronchoscopy revealed complete closure of the fistula with granulation tissue developing around the device.

glues are ineffective as it spills into the pleural space or contralateral bronchus. Various devices have been utilized for the closure of BPF, such as endobronchial valves, stents, spigots, and septal occluder device.1–3 Only 3 cases have been reported to date demonstrating the use of septal occluder device for the closure of BPF involving the major airways. We present a case of chronic postoperative broncho-pleuro-cutaneous fistula, which persisted for 6 years before it was successfully closed with transcutaneous delivery of septal occluder device. The septal occluder device has been employed by cardiologists for the closure of atrial septal defects. It is a self-expanding double disk joined by connecting mesh tube. It is made of nitinol wire mesh with polyester patches sewn within the disks and central mesh tube. The


Bronchopleural fistula involving the central airways require devices for closure as biological

FIGURE 3. Atrial septal occluder device with double disks. r

2014 Lippincott Williams & Wilkins

FIGURE 4. Chest radiograph (arrow) showing septal occluder device at carina. |


Marwah et al

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waist size varies from 4 to 40 mm, and it serves to self-center the device during deployment. In contrast to other case reports,4,5 we applied the device in a patient who failed surgical closure twice and had persistent fistula for 6 years. Our patient had developed postoperative empyema with BPF and had undergone creation of modified Eloesser flap; the latter is an openwindow thoracostomy procedure performed for the drainage of empyema cavity. It is an externalization procedure for unroofing the empyema cavity at the most dependent point. It is usually performed in debilitated patients with postoperative thoracic empyema and BPF in whom thoracoplasty is not a viable alternative.6 The originally intended valve mechanism of the Eloesser flap was introduced in 1935.7 It went through several modifications, reaching the present form called modified Eloesser flap, where the inverted flap is attached to the floor of the cavity. Maintenance of the flap requires daily packing.8 It differs from the Clagett procedure, which is a complex-staged procedure consisting of open pleural drainage, serial operative debridement, and eventual chest closure after filling the pleural cavity with antibiotic solution.9 The guidewire in our case was delivered through the working channel of the bronchoscope into the pleura and then snared through the modified Eloesser flap. The device was then deployed through the sheath over the guidewire transcutaneously and the position was ascertained by the flexible bronchoscope. The granulation tissue has developed around the device and we expect

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that it would gradually cover the device completely. CONCLUSIONS

This case report highlights the role of an atrial septal occluder device in closure of chronic BPF involving the proximal airways, which cannot be closed surgically. REFERENCES 1. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–3965. 2. Paul S, Talbot SG, Carty M, et al. Bronchopleural fistula repair during Clagett closure utilizing a collagen matrix plug. Ann Thorac Surg. 2007;83:1519–1521. 3. Kim KH, Lee KH, Won JY, et al. Bronchopleural fistula treatment with use of a bronchial stent-graft occlude. J Vasc Interv Radiol. 2006;17:1539–1543. 4. Goblin JM, Prakash UB, Blanco RE. A 57-year-old man with end-stage renal disease and chronic cough. Chest. 2008;133:1021–1024. 5. Kramer MR, Peled N, Shitrit D, et al. Use of Amplatzer device for endobronchial closure of bronchopleural fistulas. Chest. 2008;133:1481–1484. 6. Miller JI. Postsurgical empyema. In: Shields TW, Lo Cicero J Jr, Ponn RB, eds. General Thoracic Surgery. 5th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2000:709–716. 7. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet. 1935;60:1096–1097. 8. Thourani VH, Lancaster RT, Mansour KA, et al. Twenty-six years of experience with the modified eloesser flap. Ann Thorac Surg. 2003;76:401–406. 9. Zaheer S, Allen MS, Cassivi SD, et al. Postpneumonectomy empyema: results after the Clagett procedure. Ann Thorac Surg. 2006;82:279–286.


2014 Lippincott Williams & Wilkins

Closure of chronic bronchopleural fistula using atrial septal occluder device.

Chronic persistent bronchopleural fistulae (BPF) are challenging management problems. The management of BPF includes various surgical and medical proc...
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