Download PDF
Semin intervent Radiol 2004; 21(4): 283-295
DOI: 10.1055/s-2004-861563
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Interventional Techniques in the Management of Airway Complications Following Lung Transplantation

Nikhil B. Amesur1 , Philip D. Orons2 , Aldo T. Iacono3
  • 1Assistant Professor of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 2Associate Professor of Radiology and Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 3Associate Professor of Medicine and Surgery, Division of Pulmonary Transplant Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Further Information

Publication History

Publication Date:
07 January 2005 (online)

Also available at
    Permissions and Reprints

ABSTRACT

The last four decades have seen tremendous advances in the field of pulmonary transplantation. Vast improvements in the areas of surgical transplantation techniques, immunosuppressive agents, and postoperative care have all contributed to improved survival of patients. Advances in noninvasive imaging and bronchoscopy have allowed the pulmonary transplant team to intervene early in patients presenting with airway complications, often using minimally invasive procedures such as endobronchial balloon dilation or stent placement, or both. Stent technology itself has also improved and stents may sometimes be customized for treatment of short airway lesions or to optimize continued airflow through the sides of stents by creating openings using balloons or bronchoscopically directed laser. Preliminary work with brachytherapy may be decreasing the need for secondary reinterventions. The authors present an overview of some of these conventional and novel approaches to the treatment of airway complications after lung transplantation.

KEYWORDS

Lung transplantation - bronchus - stenosis

REFERENCES

  • 1 Hardy J, Webb W, Dalton M et al.. Lung homotransplantations in man.  JAMA. 1963;  186 1065-1074
    CrossrefPubMedSearch in Google Scholar
  • 2 Hardy J D. The first lung transplant in man (1963) and the first heart transplant in man (1964).  Transplant Proc. 1999;  31 25-29
    CrossrefPubMedSearch in Google Scholar
  • 3 Based on Organ Procurement and Transplantation Network data as of January 12 2004
  • 4 Barr M L, Schenkel R G, Cohen R G et al.. Recipient and donor outcomes in living related and unrelated lobar transplantation.  Transplant Proc. 1998;  30 2261-2263
    CrossrefPubMedSearch in Google Scholar
  • 5 Grover F L, Fullerton D A, Zamora M R et al.. The past, present, and future of lung transplantation.  Am J Surg. 1997;  173 523-533
    CrossrefPubMedSearch in Google Scholar
  • 6 Derom F, Barbier F, Ringoi S et al.. Ten month survival after lung homotransplantations in man.  J Thorac Cardiovasc Surg. 1971;  61 835-846
    PubMedSearch in Google Scholar
  • 7 Veith F J, Kambolg S L, Mollenkopf F P, Montefusco C M. Lung transplantation.  Transplantation. 1983;  35 271-278
    PubMedSearch in Google Scholar
  • 8 Schafers H J, Haydock D A, Cooper J D. The prevalence and management of bronchial anastomotic complications in lung transplantation.  J Thorac Cardiovasc Surg. 1991;  101 1044-1052
    PubMedSearch in Google Scholar
  • 9 Lau C L, Patterson G A. Technical considerations in lung transplantation.  Chest Surg Clin N Am. 2003;  13 463-483
    PubMedSearch in Google Scholar
  • 10 Meyers B F, Patterson G A. Technical aspects of adult lung transplantation.  Semin Thorac Cardiovasc Surg. 1998;  10 213-220
    PubMedSearch in Google Scholar
  • 11 Patterson G A. Bilateral lung transplant: indications and technique.  Semin Thorac Cardiovasc Surg. 1992;  4 95-100
    PubMedSearch in Google Scholar
  • 12 Patterson G A, Cooper J D, Goldman B et al.. Technique of successful clinical double-lung transplantation.  Ann Thorac Surg. 1988;  45 626-633
    CrossrefPubMedSearch in Google Scholar
  • 13 Cooper J D, Pearson F G, Patterson G A et al.. Technique of successful lung transplantation in humans.  J Thorac Cardiovasc Surg. 1987;  93 173-181
    PubMedSearch in Google Scholar
  • 14 van den Berg J WK, Postma D S, Koeter G H, van der Bij W. New immunosuppressive drugs and lung transplantation: last or least?.  Thorax. 1999;  54 550-553
    PubMedSearch in Google Scholar
  • 15 Lima O, Cooper J D, Peters W J et al.. Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation.  J Thorac Cardiovasc Surg. 1981;  82 211-215
    PubMedSearch in Google Scholar
  • 16 Goldberg M, Lima O, Morgan E et al.. A comparison between cyclosporine A and methylprednisolone plus azathioprine on bronchial healing following canine lung autotransplantation.  J Thorac Cardiovasc Surg. 1983;  85 821-826
    PubMedSearch in Google Scholar
  • 17 Dransfield M T, Garver R I, Weill D. Standardized guidelines for surveillance bronchoscopy reduce complications in lung transplant recipients.  J Heart Lung Transplant. 2004;  23 110-114
    PubMedSearch in Google Scholar
  • 18 Westall G P, Michaelides A, Williams T J, Snell G I, Kotsimbos T C. Bronchiolitis obliterans syndrome and early human cytomegalovirus DNAaemia dynamics after lung transplantation.  Transplantation. 2003;  75 2064-2068
    CrossrefPubMedSearch in Google Scholar
  • 19 Corris P A. Lung transplantation. Bronchiolitis obliterans syndrome.  Chest Surg Clin N Am. 2003;  13 543-557
    PubMedSearch in Google Scholar
  • 20 Boehler A, Estenne M. Obliterative bronchiolitis after lung transplantation.  Curr Opin Pulm Med. 2000;  6 133-139
    CrossrefPubMedSearch in Google Scholar
  • 21 Wildevuur C R, Benfield J R. A review of 23 human lung transplantations by 20 surgeons.  Ann Thorac Surg. 1970;  9 489-515
    CrossrefPubMedSearch in Google Scholar
  • 22 Kshettry V R, Kroshus T J, Hertz M I et al.. Early and late airway complications after lung transplantation: incidence and management.  Ann Thorac Surg. 1997;  63 1576-1583
    CrossrefPubMedSearch in Google Scholar
  • 23 Herrera J M, McNeil K D, Higgins R SD et al.. Airway complications after lung transplantation: treatment and long-term outcome.  Ann Thorac Surg. 2001;  71 989-994
    Search in Google Scholar
  • 24 Date H, Trulock E P, Arcidi J M, Sundaresan S, Cooper J D, Patterson G A. Improved airway healing after lung transplantation. An analysis of 348 bronchial anastomoses.  J Thorac Cardiovasc Surg. 1995;  110 1424-1433
    PubMedSearch in Google Scholar
  • 25 Couraud L, Nashef S A, Nicolini P, Jougon J. Classification of airway anastomotic healing.  Eur J Cardiothorac Surg. 1992;  6 496-497
    CrossrefPubMedSearch in Google Scholar
  • 26 Norgaard M A, Andersen C B, Pettersson G. Does bronchial artery revascularization influence results concerning bronchiolitis obliterans syndrome and/or obliterative bronchiolitis after lung transplantation?.  Eur J Cardiothorac Surg. 1998;  14 311-318
    PubMedSearch in Google Scholar
  • 27 Norgaard M A, Andersen C B, Pettersson G. Airway epithelium of transplanted lungs with and without direct bronchial artery revascularization.  Eur J Cardiothorac Surg. 1999;  15 37-44
    CrossrefPubMedSearch in Google Scholar
  • 28 Siegelmann S S, Hagstrom J WC, Koerner S K, Veith F J. Restoration of bronchial artery circulation after canine lung allograft transplantation.  J Thorac Cardiovasc Surg. 1977;  73 792-795
    PubMedSearch in Google Scholar
  • 29 Mulligan M S. Endoscopic management of airway complications after lung transplantation.  Chest Surg Clin N Am. 2001;  11 907-915
    PubMedSearch in Google Scholar
  • 30 Couraud L, Bauded E, Nashef S AM et al.. Lung transplantation with bronchial revascularization.  Eur J Cardiothorac Surg. 1992;  6 490-495
    CrossrefPubMedSearch in Google Scholar
  • 31 Cauldwell E W, Siekert R G, Lininger R E, Anson B J. The bronchial arteries: an anatomic study of 150 human cadavers.  Surg Gynecol Obstet. 1948;  86 395-412
    PubMedSearch in Google Scholar
  • 32 Morgan E, Lima O, Goldberg M, Ferdman A, Luk S K, Cooper J D. Successful revascularization of totally ischemic bronchial autograft with omental pedicle flaps in dogs.  J Thorac Cardiovasc Surg. 1982;  84 204-210
    PubMedSearch in Google Scholar
  • 33 Fell S C, Mollenkopf F P, Montefusco C M et al.. Revascularization of ischemic bronchial anastomosis by an intercostal pedicle flap.  J Thorac Cardiovasc Surg. 1985;  90 172-178
    PubMedSearch in Google Scholar
  • 34 Pinkser K L, Koerner S K, Kamholz S L, Hagstrom J WC, Veith F J. Effect of donor bronchial length on healing: a canine model to evaluate bronchial anastomotic problems in lung transplantation.  J Thorac Cardiovasc Surg. 1979;  77 669-673
    PubMedSearch in Google Scholar
  • 35 Schafers J H, Haverich A, Wagner T OF, Wahler T, Alken A, Borst H G. Decreased incidence of bronchial complications following lung transplantation.  Eur J Cardiothorac Surg. 1992;  6 174-179
    CrossrefPubMedSearch in Google Scholar
  • 36 Chhajed P N, Malouf M A, Tamm M, Spratt P, Glanville A R. Interventional bronchoscopy for the management of airway complications following lung transplantation.  Chest. 2001;  120 1894-1899
    CrossrefPubMedSearch in Google Scholar
  • 37 Orons P D, Amesur N B, Dauber J H, Zajko A B, Keenan R J, Iacono A T. Balloon dilation and endobronchial stent placement for bronchial strictures after lung transplantation.  J Vasc Interv Radiol. 2000;  11 89-99
    CrossrefPubMedSearch in Google Scholar
  • 38 Burns K E, Orons P D, Dauber J H et al.. Endobronchial metallic stent placement for airway complications after lung transplantation: longitudinal results.  Ann Thorac Surg. 2002;  74 1934-1941
    Search in Google Scholar
  • 39 Kazerooni E A, Chow L C, Whyte R I et al.. Preoperative examination of lung transplant candidates: value of chest CT compared with chest radiography.  AJR Am J Roentgenol. 1995;  165 1343-1348
    PubMedSearch in Google Scholar
  • 40 Collins J. Imaging of the chest after lung transplantation.  J Thorac Imaging. 2002;  17 102-112
    CrossrefPubMedSearch in Google Scholar
  • 41 Collins J, Kuhlman J E, Love R B. Acute, life-threatening complications of lung transplantation.  Radiographics. 1998;  18 21-43
    PubMedSearch in Google Scholar
  • 42 Konen E, Yellin A, Greenber I et al.. Complications of tracheal and thoracic surgery: the role of multisection helical CT and computerized reformations.  Clin Radiol. 2003;  58 341-350
    CrossrefPubMedSearch in Google Scholar
  • 43 Collins J, Hartman M J, Warner T F et al.. Frequency and CT findings of recurrent disease after lung transplantation.  Radiology. 2001;  219 503-509
    CrossrefPubMedSearch in Google Scholar
  • 44 Schlueter F J, Semenkovich J W, Glazer H S, Arcidi J M, Trulock E P, Patterson G A. Bronchial dehiscence after lung transplantation: correlation of CT findings with clinical outcomes.  Radiology. 1996;  199 849-854
    PubMedSearch in Google Scholar
  • 45 Semenkovich J W, Glazer H S, Anderson D J, Arcidi J, Cooper J D, Patterson G A. Bronchial dehiscence in lung transplantation: CT evaluation.  Radiology. 1995;  194 205-208
    PubMedSearch in Google Scholar
  • 46 Siegel M J, Bhalla S, Gutierrez F R, Hildebolt C, Sweet S. Post-lung transplantation bronchiolitis obliterans syndrome: usefulness of expiratory thin- section CT for diagnosis.  Radiology. 2001;  220 455-462
    PubMedSearch in Google Scholar
  • 47 McAdams H P, Erasmus J J, Palmer S M. Complications (excluding hyperinflation) involving the native lung after single-lung transplantation: incidence, radiologic features, and clinical importance.  Radiology. 2001;  218 233-241
    PubMedSearch in Google Scholar
  • 48 Hearne S E, O'Laughlin M P, Davis R D, Baker W A, Bashore T M, Harrison J K. Total pulmonary artery occlusion immediately after lung transplantation: successful revascularization with intravascular stents.  J Heart Lung Transplant. 1996;  15 532-535
    PubMedSearch in Google Scholar
  • 49 Berger H, Steiner W, Schmidt D, Forst H, Dienemann H. Stent-angioplasty of an anastomotic stenosis of the pulmonary artery after lung transplantation.  Eur J Cardiothorac Surg. 1994;  8 103-105
    CrossrefPubMedSearch in Google Scholar
  • 50 Yoon H, Huddleston C B, Miyoshi S, Matsuda H, Kamiike W, Patterson G A. Pulmonary function after living donor lung transplantation.  Transplant Proc. 2001;  33 1626-1627
    CrossrefPubMedSearch in Google Scholar
  • 51 Sritippayawan S, Keens T G, Horn M V, Starnes V A, Woo M S. What are the best pulmonary function test parameters for early detection of post-lung transplant bronchiolitis obliterans syndrome in children?.  Pediatr Transplant. 2003;  7 200-203
    CrossrefPubMedSearch in Google Scholar
  • 52 Trulock E P. Flexible bronchoscopy in lung transplantation.  Clin Chest Med. 1999;  20 77-87
    PubMedSearch in Google Scholar
  • 53 Rio B, Guesde R, Jacquens Y et al.. Fiberoptic bronchoscopy in brain-dead organ donors.  Am J Respir Crit Care Med. 1994;  150 558-560
    PubMedSearch in Google Scholar
  • 54 Kukafka D S, O’Brien G M, Furukawa S, Criner G. Surveillance bronchoscopy in lung transplant recipients.  Chest. 1997;  111 377-381
    CrossrefPubMedSearch in Google Scholar
  • 55 Iacono A T, Corcoran T E, Griffith B P et al.. Aerosol cyclosporin therapy in lung transplant recipients with bronchiolitis obliterans.  Eur Respir J. 2004;  23 384-390
    CrossrefPubMedSearch in Google Scholar
  • 56 Corcoran T E, Smaldone G C, Dauber J H et al.. Preservation of post-transplant lung function with aerosol cyclosporine.  Eur Respir J. 2004;  23 378-383
    CrossrefPubMedSearch in Google Scholar
  • 57 Baz M A, Layish D T, Govert J A et al.. Diagnostic yield of bronchoscopies after isolated lung transplantation.  Chest. 1996;  110 84-88
    CrossrefPubMedSearch in Google Scholar
  • 58 Kelly W F, Sanghani S, Barnett S D, Burton N, Nathan S. Significance of early bronchoscopic airway abnormalities after lung transplantation.  J Heart Lung Transplant. 2003;  22 583-586
    PubMedSearch in Google Scholar
  • 59 Spatenka J, Khaghani A, Irving J D, Theodoropoulos S, Slavik Z, Yacoub M H. Gianturco self-expanding metallic stents in treatment of tracheobronchial stenosis after single lung and heart and lung transplantation.  Eur J Cardiothorac Surg. 1991;  5 648-652
    CrossrefPubMedSearch in Google Scholar
  • 60 Carre P, Rousseau H, Lombart L et al.. Balloon dilatation and self-expanding metal Wallstent insertion. For management of bronchostenosis following lung transplantation. The Toulouse Lung Transplantation Group.  Chest. 1994;  105 343-348
    CrossrefPubMedSearch in Google Scholar
  • 61 Higgins R, McNeil K, Dennis C et al.. Airway stenoses after lung transplantation: management with expanding metal stents.  J Heart Lung Transplant. 1994;  13 774-778
    PubMedSearch in Google Scholar
  • 62 Sonett J R, Keenan R J, Ferson P F, Griffith B P, Landreneau R J. Endobronchial management of benign, malignant, and lung transplantation airway stenoses.  Ann Thorac Surg. 1995;  59 1417-1422
    CrossrefPubMedSearch in Google Scholar
  • 63 Susanto I, Peters J I, Levine S M, Sako E Y, Anzueto A, Bryan C L. Use of balloon-expandable metallic stents in the management of bronchial stenosis and bronchomalacia after lung transplantation.  Chest. 1998;  114 1330-1335
    CrossrefPubMedSearch in Google Scholar
  • 64 Lonchyna V A, Arcidi Jr J M, Garrity Jr E R et al.. Refractory post-transplant airway strictures: successful management with wire stents.  Eur J Cardiothorac Surg. 1999;  15 842-849
    CrossrefPubMedSearch in Google Scholar
  • 65 Mulligan M S. Endoscopic management of airway complications after lung transplantation.  Chest Surg Clin N Am. 2001;  11 907-915
    PubMedSearch in Google Scholar
  • 66 Chhajed P N, Malouf M A, Tamm M, Glanville A R. Ultraflex stents for the management of airway complications in lung transplant recipients.  Respirology. 2003;  8 59-64
    CrossrefPubMedSearch in Google Scholar
  • 67 Perini S, Gordon R, Golden J et al.. Deformation and migration of Palmaz stents after placement in the tracheobronchial tree.  J Vasc Interv Radiol. 1999;  10 209-215
    PubMedSearch in Google Scholar
  • 68 Sonett J R, Conte J V, Orens J, Krasna M. Removal and repositioning of “permanent” expandable wire stents in bronchial airway stenosis after lung transplantation.  J Heart Lung Transplant. 1998;  17 328-330
    Search in Google Scholar
  • 69 Susanto I, Peters J I, Levine S M, Sako E Y, Anzueto A, Bryan C L. Use of balloon-expandable metallic stents in the management of bronchial stenosis and bronchomalacia after lung transplantation.  Chest. 1998;  114 1330-1335
    CrossrefPubMedSearch in Google Scholar
  • 70 Saad C P, Ghamande S A, Minai O A et al.. The role of self-expandable metallic stents for the treatment of airway complications after lung transplantation.  Transplantation. 2003;  75 1532-1538
    CrossrefPubMedSearch in Google Scholar
  • 71 Burns K E, Iacono A T. Incidence of clinically unsuspected pulmonary embolism in mechanically ventilated lung transplant recipients.  Transplantation. 2003;  76 964-968
    PubMedSearch in Google Scholar
  • 72 Clark S C, Levine A J, Hasan A, Hilton C J, Forty J, Dark J H. Vascular complications of lung transplantation.  Ann Thorac Surg. 1996;  61 1079-1082
    CrossrefPubMedSearch in Google Scholar
  • 73 Waurick P E, Kleber F X, Ewert R et al.. Pulmonary artery stenosis 5 years after single lung transplantation in primary pulmonary hypertension.  J Heart Lung Transplant. 1999;  18 1243-1245
    CrossrefPubMedSearch in Google Scholar
  • 74 Pearson F G, Goldberg M, Stone R M, Colapinto R F. Bronchial arterial circulation restored after reimplantation of canine lung.  Can J Surg. 1970;  13 243-250
    PubMedSearch in Google Scholar
  • 75 Schoenberger J A, Darcy M D. Bronchial artery embolization for hemoptysis in a lung transplant recipient.  J Vasc Interv Radiol. 1995;  6 354-356
    PubMedSearch in Google Scholar
  • 76 Kennedy A S, Sonett J R, Orens J B, King K. High dose rate brachytherapy to prevent recurrent benign hyperplasia in lung transplant bronchi: theoretical and clinical considerations.  J Heart Lung Transplant. 2000;  19 155-159
    PubMedSearch in Google Scholar
  • 77 Halkos M E, Godette K D, Lawrence E C, Miller Jr J I. High dose rate brachytherapy in the management of lung transplant airway stenosis.  Ann Thorac Surg. 2003;  76 381-384
    CrossrefPubMedSearch in Google Scholar

Nikhil B AmesurM.D. 

Assistant Professor of Radiology, University of Pittsburgh Medical Center

200 Lothrop Street, Childrens Main Tower 4886

Pittsburgh, PA 15213