Catheter-Interventional Closure of a Bronchopleural Fistula by Means of Microcoils

Objectives: Bronchopleural fistula in sequelae of a severe pneumonia, lung abscessus, or empyema is a rare but severe complication. For therapeutic options, collaboration with the pediatric interventional cardiologist may be the best option as in our case. We report on a 2.5-year-old girl presenting with high fever, tachydyspnea, and respiratory distress with back pain and cough on admission. A right-sided pneumonia and pleural effusion were stated by chest X-ray and subsequent HRCT. CRP was elevated to 25 mg/dL. The girl was started on antibiotics, noninvasive ventilation, and received a pleural drainage. After first removal of the chest tube 3 days after cessation of secretions, a valvular pneumothorax occurred requiring a pleural drainage again. With the new drainage, a persistent air-leak remained for more than 3 weeks. Further imaging by CT and endoscopic bronchography revealed a right-sided bronchopleural fistula, originating from bronchial segment 3.

Methods: After interdisciplinary discussion, an interventional approach by the pediatric cardiologist was preferred using vascular plug-like devices. However, in contrast to vascular interventions, an air-tight closure without helpful coagulation was needed. The devices of choice were four vascular coils differing in size and length as used with the neuroradiologists. In a combined bronchoscopy and bronchography, a hydrophilic angiographic catheter was placed in segment bronchus 3 of right upper lobe enabling superselective embolization of four large-volume platinum embolization device to achieve higher packing densities (2 mm × 3 cm, 3 mm × 5 cm, and 4 mm ×6 cm). Subsequent bronchography proved leak tightness.

Result: Two days later, the drainage could be removed and the child was extubated. On follow-up, over 2 years, main coil position remained unchanged and right-sided chest X-ray controls normalized with no relapse of pneumothorax.

Conclusion: A bronchopleural fistula is a severe complication of pneumonia or lung abscessus. Besides a more invasive option by VATS in older children, chemical intervention by topic administration of ethanol, sliver nitrate, cyanoacrylate, fibrin glue, polyethylenglycol, doxycycline, or cellulose have been published. However, due to the young age and very small anatomy in this child, we decided for a, to date, nonpublished interventional approach by means of four high-density packing microcoils. By this, a rapid removal of the chest drainage, extubation, and discharge was possible.

Publication History

Article published online:
21 February 2021