Late onset of pneumothorax after bronchoscopic lung volume reduction due to migration of a nitinol coil

Late onset of pneumothorax after bronchoscopic lung volume reduction due to migration of a... Abstract The use of Endobronchial coils are a relatively new brochoscopic technique for lung volume reduction. They appear to be safe and effective in improving quality of life, reducing morbidity and mortality related to the primary disease, while avoiding the many risks of morbidity and mortality associated with surgery. Nevertheless, some complications, such as pneumothorax, are relatively common in the periprocedural period. We describe a case of pneumothorax that occurred several days after brochoscopic technique for lung volume reduction due to direct perforation of the visceral pleura by a coil. The patient presented with a large pneumothorax associated with significant air leak, requiring surgical intervention. Exploration of the chest cavity showed a pleural tear caused by a coil. To our knowledge, this is an adverse event that has never been described before, suggesting the possible migration of the coil from the original position. Bronchoscopic lung volume reduction, Nitinol coils, Complications INTRODUCTION Surgical treatments for end-stage emphysema include lung transplantation and lung volume reduction surgery [1]. However, strict patient selection criteria and high morbidity rates exclude the use of these procedures in many cases [2]. This has led to the development of alternative bronchoscopic techniques that can be used in patients with no indication for lung transplantation or as a bridge to lung transplantation. Of the several treatment options, nitinol coils have demonstrated promising results and acceptable rates of complication. They can be used in patients with both homogeneous and heterogeneous emphysema [2] and without the mechanism of action requiring collateral ventilation. Unlike valves, coils do not appear to migrate or dislodge, even up to 4 years after implantation [3]. Pneumothorax (PNX) is a known complication, usually caused by a sudden reduction of the lobe volume. We describe the case of a late-onset tension PNX caused by a coil directly injuring the visceral pleura, thus requiring surgical intervention. CASE REPORT A 63-year-old woman affected by end-stage emphysema underwent a brochoscopic technique for lung volume reduction involving the insertion of nitinol coils in the right upper lobe, with the contralateral procedure having been performed several months previously. The procedure was performed under general anaesthesia using fluoroscopic guidance. All coils were implanted along a guidewire, at a distance of >35 mm from the pleural edge. Post-procedural chest film was obtained to rule out PNX, the patient was observed for 24 h and subsequently discharged. Four days later, she presented at the emergency department with the sudden onset of severe dyspnoea. A PNX was confirmed by an X-ray (Fig. 1), and a chest drain was inserted. As a result of a prolonged and consistent air leak, a video-assisted thoracoscopy was performed, showing the presence of a coil perforating the visceral pleura in the right upper lobe (Fig. 2). The coil was easily removed, and a wedge resection of the lung, including a sizeable defect in the visceral pleura, was performed. The postoperative period was uneventful, allowing drain removal on the 3rd postoperative day. Figure 1: View largeDownload slide Chest X-ray showing a large right pneumothorax with possible coil dislocation (white arrow). Figure 1: View largeDownload slide Chest X-ray showing a large right pneumothorax with possible coil dislocation (white arrow). Figure 2: View largeDownload slide Intraoperative view showing a coil abutting the pleural surface (white arrow). Figure 2: View largeDownload slide Intraoperative view showing a coil abutting the pleural surface (white arrow). DISCUSSION PNX after brochoscopic technique for lung volume reduction is a well-known complication. After valve placement, it can occur several days later, positively correlated with atelectasis of the treated lobe. Coils do not cause atelectasis, but they increase elastic recoil in the diseased lung by gathering and compressing the hyperinflated parenchyma. They are available in different sizes and are straightened in dedicated catheters for delivery into the target subsegmental airways under fluoroscopy. Once released, they regain their 3D shape shortening the airway. Expiratory airway collapse is also reduced by the radial traction improving dynamic gas trapping and hyperinflation. In all reported series, PNX usually occurs immediately after the procedure, and to date, the need for surgical intervention has not been reported [2–4]. These findings suggest a pathogenesis of the PNX related to sudden shrinking of the parenchyma or, in the rare cases of late onset, may be related to the primary disease [5]. Moreover, pathological examination of lung tissue obtained from patients undergoing lung transplantation after coil implants demonstrated the stability of the coils in the targeted segments, surrounded by organizing reaction, suggesting micromovements of the coils without the tendency to migrate [3]. In our case, the post-procedural radiograph showed optimal positioning of the coils without complication, with the PNX occurring much later. Thus, having caused a large air leak, the conservative management was not advisable, with surgical intervention being almost mandatory. Thoracoscopic exploration showed a large defect in the visceral pleura with a coil abutting the surface of the lung. The clinical evidence of this case is in keeping with the migration of a coil that, to our knowledge, has never been described. Possible size mismatch or perforation of the subsegmental bronchial wall could have been a potential mechanism of migration. Longer hospital stay for observation in patients with vanishing lung syndrome in target areas could be indicated. Conflict of interest: none declared. REFERENCES 1 van Geffen WH, Kerstjens HAM, Slebos DJ. Emerging bronchoscopic treatments for chronic obstructive pulmonary disease. Pharmacol Ther  2017; 179: 96– 101. Google Scholar CrossRef Search ADS PubMed  2 Slebos DJ, Hartman JE, Klooster K, Blaas S, Deslee G, Gesierich W et al.   Bronchoscopic coil treatment for patients with severe emphysema: a meta-analysis. Respiration  2015; 90: 136– 45. Google Scholar CrossRef Search ADS PubMed  3 Hartman JE, Klooster K, Gortzak K, ten Hacken NH, Slebos DJ. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology  2015; 20: 319– 26. Google Scholar CrossRef Search ADS PubMed  4 Deslee G, Klooster K, Hetzel M, Stanzel F, Kessler R, Marquette CH et al.   Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial. Thorax  2014; 69: 980– 6. Google Scholar CrossRef Search ADS PubMed  5 Sciurba FC, Criner GJ, Strange C, Shah PL, Michaud G, Connolly TA et al.   Effect of endobronchial coils vs usual care on exercise tolerance in patients with severe emphysema: the RENEW randomized clinical trial. JAMA  2016; 315: 2178– 89. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Late onset of pneumothorax after bronchoscopic lung volume reduction due to migration of a nitinol coil

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Publisher
Oxford University Press
ISSN
1010-7940
eISSN
1873-734X
D.O.I.
10.1093/ejcts/ezx402
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Abstract

Abstract The use of Endobronchial coils are a relatively new brochoscopic technique for lung volume reduction. They appear to be safe and effective in improving quality of life, reducing morbidity and mortality related to the primary disease, while avoiding the many risks of morbidity and mortality associated with surgery. Nevertheless, some complications, such as pneumothorax, are relatively common in the periprocedural period. We describe a case of pneumothorax that occurred several days after brochoscopic technique for lung volume reduction due to direct perforation of the visceral pleura by a coil. The patient presented with a large pneumothorax associated with significant air leak, requiring surgical intervention. Exploration of the chest cavity showed a pleural tear caused by a coil. To our knowledge, this is an adverse event that has never been described before, suggesting the possible migration of the coil from the original position. Bronchoscopic lung volume reduction, Nitinol coils, Complications INTRODUCTION Surgical treatments for end-stage emphysema include lung transplantation and lung volume reduction surgery [1]. However, strict patient selection criteria and high morbidity rates exclude the use of these procedures in many cases [2]. This has led to the development of alternative bronchoscopic techniques that can be used in patients with no indication for lung transplantation or as a bridge to lung transplantation. Of the several treatment options, nitinol coils have demonstrated promising results and acceptable rates of complication. They can be used in patients with both homogeneous and heterogeneous emphysema [2] and without the mechanism of action requiring collateral ventilation. Unlike valves, coils do not appear to migrate or dislodge, even up to 4 years after implantation [3]. Pneumothorax (PNX) is a known complication, usually caused by a sudden reduction of the lobe volume. We describe the case of a late-onset tension PNX caused by a coil directly injuring the visceral pleura, thus requiring surgical intervention. CASE REPORT A 63-year-old woman affected by end-stage emphysema underwent a brochoscopic technique for lung volume reduction involving the insertion of nitinol coils in the right upper lobe, with the contralateral procedure having been performed several months previously. The procedure was performed under general anaesthesia using fluoroscopic guidance. All coils were implanted along a guidewire, at a distance of >35 mm from the pleural edge. Post-procedural chest film was obtained to rule out PNX, the patient was observed for 24 h and subsequently discharged. Four days later, she presented at the emergency department with the sudden onset of severe dyspnoea. A PNX was confirmed by an X-ray (Fig. 1), and a chest drain was inserted. As a result of a prolonged and consistent air leak, a video-assisted thoracoscopy was performed, showing the presence of a coil perforating the visceral pleura in the right upper lobe (Fig. 2). The coil was easily removed, and a wedge resection of the lung, including a sizeable defect in the visceral pleura, was performed. The postoperative period was uneventful, allowing drain removal on the 3rd postoperative day. Figure 1: View largeDownload slide Chest X-ray showing a large right pneumothorax with possible coil dislocation (white arrow). Figure 1: View largeDownload slide Chest X-ray showing a large right pneumothorax with possible coil dislocation (white arrow). Figure 2: View largeDownload slide Intraoperative view showing a coil abutting the pleural surface (white arrow). Figure 2: View largeDownload slide Intraoperative view showing a coil abutting the pleural surface (white arrow). DISCUSSION PNX after brochoscopic technique for lung volume reduction is a well-known complication. After valve placement, it can occur several days later, positively correlated with atelectasis of the treated lobe. Coils do not cause atelectasis, but they increase elastic recoil in the diseased lung by gathering and compressing the hyperinflated parenchyma. They are available in different sizes and are straightened in dedicated catheters for delivery into the target subsegmental airways under fluoroscopy. Once released, they regain their 3D shape shortening the airway. Expiratory airway collapse is also reduced by the radial traction improving dynamic gas trapping and hyperinflation. In all reported series, PNX usually occurs immediately after the procedure, and to date, the need for surgical intervention has not been reported [2–4]. These findings suggest a pathogenesis of the PNX related to sudden shrinking of the parenchyma or, in the rare cases of late onset, may be related to the primary disease [5]. Moreover, pathological examination of lung tissue obtained from patients undergoing lung transplantation after coil implants demonstrated the stability of the coils in the targeted segments, surrounded by organizing reaction, suggesting micromovements of the coils without the tendency to migrate [3]. In our case, the post-procedural radiograph showed optimal positioning of the coils without complication, with the PNX occurring much later. Thus, having caused a large air leak, the conservative management was not advisable, with surgical intervention being almost mandatory. Thoracoscopic exploration showed a large defect in the visceral pleura with a coil abutting the surface of the lung. The clinical evidence of this case is in keeping with the migration of a coil that, to our knowledge, has never been described. Possible size mismatch or perforation of the subsegmental bronchial wall could have been a potential mechanism of migration. Longer hospital stay for observation in patients with vanishing lung syndrome in target areas could be indicated. Conflict of interest: none declared. REFERENCES 1 van Geffen WH, Kerstjens HAM, Slebos DJ. Emerging bronchoscopic treatments for chronic obstructive pulmonary disease. Pharmacol Ther  2017; 179: 96– 101. Google Scholar CrossRef Search ADS PubMed  2 Slebos DJ, Hartman JE, Klooster K, Blaas S, Deslee G, Gesierich W et al.   Bronchoscopic coil treatment for patients with severe emphysema: a meta-analysis. Respiration  2015; 90: 136– 45. Google Scholar CrossRef Search ADS PubMed  3 Hartman JE, Klooster K, Gortzak K, ten Hacken NH, Slebos DJ. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology  2015; 20: 319– 26. Google Scholar CrossRef Search ADS PubMed  4 Deslee G, Klooster K, Hetzel M, Stanzel F, Kessler R, Marquette CH et al.   Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial. Thorax  2014; 69: 980– 6. Google Scholar CrossRef Search ADS PubMed  5 Sciurba FC, Criner GJ, Strange C, Shah PL, Michaud G, Connolly TA et al.   Effect of endobronchial coils vs usual care on exercise tolerance in patients with severe emphysema: the RENEW randomized clinical trial. JAMA  2016; 315: 2178– 89. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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