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
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
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
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
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
7
Veith F J, Kambolg S L, Mollenkopf F P, Montefusco C M.
Lung transplantation.
Transplantation.
1983;
35
271-278
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
9
Lau C L, Patterson G A.
Technical considerations in lung transplantation.
Chest Surg Clin N Am.
2003;
13
463-483
10
Meyers B F, Patterson G A.
Technical aspects of adult lung transplantation.
Semin Thorac Cardiovasc Surg.
1998;
10
213-220
11
Patterson G A.
Bilateral lung transplant: indications and technique.
Semin Thorac Cardiovasc Surg.
1992;
4
95-100
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
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
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
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
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
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
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
19
Corris P A.
Lung transplantation. Bronchiolitis obliterans syndrome.
Chest Surg Clin N Am.
2003;
13
543-557
20
Boehler A, Estenne M.
Obliterative bronchiolitis after lung transplantation.
Curr Opin Pulm Med.
2000;
6
133-139
21
Wildevuur C R, Benfield J R.
A review of 23 human lung transplantations by 20 surgeons.
Ann Thorac Surg.
1970;
9
489-515
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
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
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
25
Couraud L, Nashef S A, Nicolini P, Jougon J.
Classification of airway anastomotic healing.
Eur J Cardiothorac Surg.
1992;
6
496-497
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
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
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
29
Mulligan M S.
Endoscopic management of airway complications after lung transplantation.
Chest Surg Clin N Am.
2001;
11
907-915
30
Couraud L, Bauded E, Nashef S AM et al..
Lung transplantation with bronchial revascularization.
Eur J Cardiothorac Surg.
1992;
6
490-495
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
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
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
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
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
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
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
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
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
40
Collins J.
Imaging of the chest after lung transplantation.
J Thorac Imaging.
2002;
17
102-112
41
Collins J, Kuhlman J E, Love R B.
Acute, life-threatening complications of lung transplantation.
Radiographics.
1998;
18
21-43
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
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
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
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
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
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
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
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
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
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
52
Trulock E P.
Flexible bronchoscopy in lung transplantation.
Clin Chest Med.
1999;
20
77-87
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
54
Kukafka D S, O’Brien G M, Furukawa S, Criner G.
Surveillance bronchoscopy in lung transplant recipients.
Chest.
1997;
111
377-381
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
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
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
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
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
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
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
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
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
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
65
Mulligan M S.
Endoscopic management of airway complications after lung transplantation.
Chest Surg Clin N Am.
2001;
11
907-915
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
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
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
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
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
71
Burns K E, Iacono A T.
Incidence of clinically unsuspected pulmonary embolism in mechanically ventilated lung transplant recipients.
Transplantation.
2003;
76
964-968
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
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
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
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
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
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
Nikhil B AmesurM.D.
Assistant Professor of Radiology, University of Pittsburgh Medical Center
200 Lothrop Street, Childrens Main Tower 4886
Pittsburgh, PA 15213