Management of Severe Bronchial Ischemia After Bilateral Sequential Lung Transplantation Derya Oturanlar, MD, Walter Klepetko, MD, Michael Grimm, MD, Adelheid End, MD, Wilfried Wisser, MD, Thomas Wekerle, MD, and Ernst Wolner, MD Second Surgical Department University of Vienna, Vienna, Austria
A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed. (Ann Thorac Surg 1992;54:1221-2)
A
lthough bronchial anastomotic complications after lung transplantation have been frequently described in the past [l], complete bronchial ischemia remains a rare event. If early bronchial dehiscence [2] does not occur, the usual result is severe instability and malacia of the bronchial system, which later on is followed by heavy shrinking and late scar formation. A 38-year-old man underwent bilateral sequential lung transplantation for treatment of end-stage emphysema. Preservation of the lungs was performed by pulmonary artery flushing with 60 mL/kg of cold modified EuroCollins solution. Ischemic time for the lungs was 300 and 394 minutes, respectively. Both anastomoses were performed using a telescope technique with interrupted 3-0 PDS (Ethicon, Germany) sutures and were wrapped with intercostal muscle flaps. Intraoperative bronchoscopy showed normal anastomoses and distal bronchial mucosa. Immunosuppression consisted of 1 g of methylprednisolone intraoperatively, followed by a regimen of cyclosporin A, azathioprine, and antithymocyte globulin for 7 days. Prednisolone was administered starting with the 14th postoperative day. The initial postoperative course was uneventful. The patient had excellent gas exchange, was extubated 32 hours after the procedure, and was transfered to the normal ward on the 5th postoperative day. On the 7th postoperative day increasing mucous production at coughing was noticed. By the 10th postoperative day the patient complained about increasing dyspnea, which made reintubation necessary. At bronchoscopy, severe bilateral ischemia of the donor bronchus, extending from the level of the anastomosis (Fig 1) down to the lower lobe segmental orifices (Fig 2), was observed. Because the Accepted for publication March 20, 1992. Address reprint requests to Dr Klepetko, Second Surgical Department, University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria.
0 1992 by The Society of Thoracic Surgeons
patient had no signs of bronchial dehiscence, conservative treatment with mechanically assisted ventilation was initiated. Three weeks later, the patient experienced spontaneous perforation of a duodenal ulcer. The ulcer was excised and oversewn, and selective proximal vagotomy was performed. At the end of the procedure bronchoscopy was performed. Still ischemic bronchial wall was visualized and a first attempt to stent both main bronchi with two 10-mm silicone stents was made. With these devices, weaning from ventilatory support was possible within few days. However, the patient still frequently required bronchoscopic suction to clear his enormous mucous secretions. In addition, it became obvious that stenting of the main bronchi was not sufficient to overcome the problem of bronchomalacia in the region of the lobar bronchi. After several attempts with different stents, complete stenting of the upper-lower lobe carina and the lobar bronchi was finally achieved by the insertion of small silicone T tubes (7 mm diameter) with their ends cut to a length to extend into the lobar bronchi down to the level of the segmental orifices (Fig 3). These stents were placed through a rigid bronchoscope, and final positioning was performed with a rigid forceps. The patient’s respiratory function improved impressively, and 84 days after the initial transplantation he was discharged from the hospital with satisfactory lung function (vital capacity 79% of predicted, forced expiratory volume in the first second 64% of predicted). One hundred sixty-three days after the transplantation he was readmitted to the hospital with sudden severe dyspnea due to stent dislocation. Repositioning of the stents was not possible, and when a suitable donor became available, bilateral sequential retransplantation through two separate thoracotomies was performed on the same day. The following postoperative course was uneventful, and the patient was discharged 22 days after the repeat transplantation. He remains in excellent clinical condition with normal lung function 1 year later. Pathological examination of the lungs revealed severe bronchomalacia of the central parts of the bronchi together with more distal localized poststenotic bronchiectasis and focal pneumonic infiltrates. No evidence of bronchiolitis or chronic rejection was found.
Comment Interruption of the bronchial nutritive circulation is known to be the major reason for impaired blood supply to the bronchial tree after lung transplantation [3]. Nor0003-4975/92/$5.00
1222
CASE REPORT OTURANLAR ET AL BRONCHIAL ISCHEMIA AFTER LUNG TRANSPLANTATION
Ann Thorac Surg 1992;54:1221-2
Fig 3. Schematic drawing of the stented bronchial area.
Fig 1. Bronchoscopic view on the 10th postoperative day. Beginning at the level of the bronchial anastomosis the bronchial mucosa appears completely ischemic.
mally, revascularization is soon achieved by intrapulmonary collaterals deriving from the pulmonary arterial system, and microcirculation plays a major role in restoration of nutritive blood supply [4]. Alternative techniques of early bronchial revascularization are omental wrapping or direct bronchial revascularization. In the patient described here, the exact reason for the complete bronchial ischemia must remain speculative. Ischemic time of the lungs did not exceed 7 hours, a period for which satisfying graft function has been observed in at least 30 other lung transplants at our institution. In addition, dissection of the bronchial tree was avoided as far as possible. Once bronchial problems after lung transplantation occur, their effective management is crucial to achieve good long-term outcome. By far most disturbances in bronchial healing occur at the site of the bronchial anastomosis and result in a localized stenosis [l, 51. Manage-
ment of these circumscript problems with endoluminal silicone stenting has been described. In contrast, the presence of complete bronchial ischemia extending over a distance of several centimeters results in complex damage to the bronchial tree with consequent necrosis of the mucosa and underlying structures and collapse of the bronchial wall. Extensive scar formation and bronchomalacia are the late sequelae, which most likely can only be treated by retransplantation. However, performing a retransplantation in the early postoperative period has a much higher risk than late repeat transplantation under stable conditions, and we therefore decided to treat our patient conservatively in the initial phase. Because initial stenting 10 days after the transplantation seemed to have a high risk for disruption of the anastomoses, the patient underwent temporary tracheostomy and mechanical ventilatory support. Three weeks later, stenting was performed at a time when healing of the bronchial anastomoses was expected to be sufficient. The use of small silicone T tubes for stenting of the lobar carina and lobar bronchi represented a new approach to the problem of extensive distal airway stenosis [l].The functional result of this procedure was surprisingly good and allowed complete rehabilitation of the patient. We have since used this approach with good results in other patients in whom a bronchial anastomotic stenosis closed to the upper lobe orifice was present.
References
Fig 2. A more distal bronchoscopic view shows the beginning of mucosa supplied with blood at the level of the lower lobe segmental ori-
1. Schaefers HJ, Haydock DA, Cooper JD. The prevalence and management of bronchial anastomotic complications in lung transplantation. J Thorac Cardiovasc Surg 1991;101:1044-52. 2. Kirk AJB, Conacher ID, Corris PA, Ashcroft T, Dark JH. Successful surgical management of bronchial dehiscence after single-lung transplantation. Ann Thorac Surg 1990;49:147-9. 3. LoCicero J, Massad M, Matano J, Greene R, Dunn M, Michaelis LL. Contribution of the bronchial circulation to lung preservation. J Thorac Cardiovasc Surg 1991;101:807-15. 4. Turrentine MW, Kesler KA, Wright CD, et al. Effect of omental, intercostal, and internal mammarv arterv uedicle wraps on bronchial healing. Ann Thorac Su& 1990A9r5769. 5, M~~~~~ JR, ~~~~i~~~ D, Winton TL, patterson GA, Late pulmonary complications of isolated lung transplantation.
A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed. (Ann Thorac Surg 1992;54:1221-2)
A
lthough bronchial anastomotic complications after lung transplantation have been frequently described in the past [l], complete bronchial ischemia remains a rare event. If early bronchial dehiscence [2] does not occur, the usual result is severe instability and malacia of the bronchial system, which later on is followed by heavy shrinking and late scar formation. A 38-year-old man underwent bilateral sequential lung transplantation for treatment of end-stage emphysema. Preservation of the lungs was performed by pulmonary artery flushing with 60 mL/kg of cold modified EuroCollins solution. Ischemic time for the lungs was 300 and 394 minutes, respectively. Both anastomoses were performed using a telescope technique with interrupted 3-0 PDS (Ethicon, Germany) sutures and were wrapped with intercostal muscle flaps. Intraoperative bronchoscopy showed normal anastomoses and distal bronchial mucosa. Immunosuppression consisted of 1 g of methylprednisolone intraoperatively, followed by a regimen of cyclosporin A, azathioprine, and antithymocyte globulin for 7 days. Prednisolone was administered starting with the 14th postoperative day. The initial postoperative course was uneventful. The patient had excellent gas exchange, was extubated 32 hours after the procedure, and was transfered to the normal ward on the 5th postoperative day. On the 7th postoperative day increasing mucous production at coughing was noticed. By the 10th postoperative day the patient complained about increasing dyspnea, which made reintubation necessary. At bronchoscopy, severe bilateral ischemia of the donor bronchus, extending from the level of the anastomosis (Fig 1) down to the lower lobe segmental orifices (Fig 2), was observed. Because the Accepted for publication March 20, 1992. Address reprint requests to Dr Klepetko, Second Surgical Department, University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria.
0 1992 by The Society of Thoracic Surgeons
patient had no signs of bronchial dehiscence, conservative treatment with mechanically assisted ventilation was initiated. Three weeks later, the patient experienced spontaneous perforation of a duodenal ulcer. The ulcer was excised and oversewn, and selective proximal vagotomy was performed. At the end of the procedure bronchoscopy was performed. Still ischemic bronchial wall was visualized and a first attempt to stent both main bronchi with two 10-mm silicone stents was made. With these devices, weaning from ventilatory support was possible within few days. However, the patient still frequently required bronchoscopic suction to clear his enormous mucous secretions. In addition, it became obvious that stenting of the main bronchi was not sufficient to overcome the problem of bronchomalacia in the region of the lobar bronchi. After several attempts with different stents, complete stenting of the upper-lower lobe carina and the lobar bronchi was finally achieved by the insertion of small silicone T tubes (7 mm diameter) with their ends cut to a length to extend into the lobar bronchi down to the level of the segmental orifices (Fig 3). These stents were placed through a rigid bronchoscope, and final positioning was performed with a rigid forceps. The patient’s respiratory function improved impressively, and 84 days after the initial transplantation he was discharged from the hospital with satisfactory lung function (vital capacity 79% of predicted, forced expiratory volume in the first second 64% of predicted). One hundred sixty-three days after the transplantation he was readmitted to the hospital with sudden severe dyspnea due to stent dislocation. Repositioning of the stents was not possible, and when a suitable donor became available, bilateral sequential retransplantation through two separate thoracotomies was performed on the same day. The following postoperative course was uneventful, and the patient was discharged 22 days after the repeat transplantation. He remains in excellent clinical condition with normal lung function 1 year later. Pathological examination of the lungs revealed severe bronchomalacia of the central parts of the bronchi together with more distal localized poststenotic bronchiectasis and focal pneumonic infiltrates. No evidence of bronchiolitis or chronic rejection was found.
Comment Interruption of the bronchial nutritive circulation is known to be the major reason for impaired blood supply to the bronchial tree after lung transplantation [3]. Nor0003-4975/92/$5.00
1222
CASE REPORT OTURANLAR ET AL BRONCHIAL ISCHEMIA AFTER LUNG TRANSPLANTATION
Ann Thorac Surg 1992;54:1221-2
Fig 3. Schematic drawing of the stented bronchial area.
Fig 1. Bronchoscopic view on the 10th postoperative day. Beginning at the level of the bronchial anastomosis the bronchial mucosa appears completely ischemic.
mally, revascularization is soon achieved by intrapulmonary collaterals deriving from the pulmonary arterial system, and microcirculation plays a major role in restoration of nutritive blood supply [4]. Alternative techniques of early bronchial revascularization are omental wrapping or direct bronchial revascularization. In the patient described here, the exact reason for the complete bronchial ischemia must remain speculative. Ischemic time of the lungs did not exceed 7 hours, a period for which satisfying graft function has been observed in at least 30 other lung transplants at our institution. In addition, dissection of the bronchial tree was avoided as far as possible. Once bronchial problems after lung transplantation occur, their effective management is crucial to achieve good long-term outcome. By far most disturbances in bronchial healing occur at the site of the bronchial anastomosis and result in a localized stenosis [l, 51. Manage-
ment of these circumscript problems with endoluminal silicone stenting has been described. In contrast, the presence of complete bronchial ischemia extending over a distance of several centimeters results in complex damage to the bronchial tree with consequent necrosis of the mucosa and underlying structures and collapse of the bronchial wall. Extensive scar formation and bronchomalacia are the late sequelae, which most likely can only be treated by retransplantation. However, performing a retransplantation in the early postoperative period has a much higher risk than late repeat transplantation under stable conditions, and we therefore decided to treat our patient conservatively in the initial phase. Because initial stenting 10 days after the transplantation seemed to have a high risk for disruption of the anastomoses, the patient underwent temporary tracheostomy and mechanical ventilatory support. Three weeks later, stenting was performed at a time when healing of the bronchial anastomoses was expected to be sufficient. The use of small silicone T tubes for stenting of the lobar carina and lobar bronchi represented a new approach to the problem of extensive distal airway stenosis [l].The functional result of this procedure was surprisingly good and allowed complete rehabilitation of the patient. We have since used this approach with good results in other patients in whom a bronchial anastomotic stenosis closed to the upper lobe orifice was present.
References
Fig 2. A more distal bronchoscopic view shows the beginning of mucosa supplied with blood at the level of the lower lobe segmental ori-
1. Schaefers HJ, Haydock DA, Cooper JD. The prevalence and management of bronchial anastomotic complications in lung transplantation. J Thorac Cardiovasc Surg 1991;101:1044-52. 2. Kirk AJB, Conacher ID, Corris PA, Ashcroft T, Dark JH. Successful surgical management of bronchial dehiscence after single-lung transplantation. Ann Thorac Surg 1990;49:147-9. 3. LoCicero J, Massad M, Matano J, Greene R, Dunn M, Michaelis LL. Contribution of the bronchial circulation to lung preservation. J Thorac Cardiovasc Surg 1991;101:807-15. 4. Turrentine MW, Kesler KA, Wright CD, et al. Effect of omental, intercostal, and internal mammarv arterv uedicle wraps on bronchial healing. Ann Thorac Su& 1990A9r5769. 5, M~~~~~ JR, ~~~~i~~~ D, Winton TL, patterson GA, Late pulmonary complications of isolated lung transplantation.
