Bronchopleural Fistula Closure with Vascular Plug and Intrapleural Glue Administration

CASE REPORT

A 20-year-old male was admitted to our hospital with a 2-week history of intermittent fever, cough, and right-sided pleuritic chest pain. On examination, there was reduced movement and air entry on the right side of the chest. On evaluation, his chest radiograph revealed right-sided loculated pleural effusion. Pleural fluid analysis was exudative, lymphocytic predominant with an adenosine deaminase of 66.9 IU/l. He was diagnosed as a case of tuberculous pleural effusion (loculated) and was started on antitubercular therapy (ATT). He was also managed with pleural catheter drainage along with intrapleural fibrinolytic therapy with urokinase for loculated pleural effusion. The cumulative dose of urokinase instilled was 5 million units. It was instilled as 50 ml normal saline solution containing 1 million units of urokinase at 8 hourly intervals with 2 h of initial clamping of tube. However, he did not respond adequately to the treatment. In view of persistent pleural thickening and young age, he underwent decortication surgery on the right side. Intraoperative findings of surgery were thick, inelastic pleural peel covering the lung surface. Postdecortication surgery, he developed BPF. He underwent bronchoscopy which localized BPF to anterior segment of the right upper lobe. He was later taken for BPF closure surgery twice, in which two ribs were excised and muscle flap closure was done. He continued to have air leak and persistent empyema [Figure 1]. Repeat evaluation revealed diffuse pleural thickening with BPF involving the anterior segment of the right upper lobe on computed tomography chest [Figures 2 and 3]. It was later confirmed on bronchoscopy using nonionic dye under fluoroscopic guidance, which showed leak of dye in pleural cavity when instilled in the anterior segment of the right upper lobe [Figure 4]. He was then taken up for bronchoscopic closure of BPF using a vascular plug. It was successfully done under fluoroscopic guidance.^[3] The procedure was carried out under conscious sedation with nasal oxygen. The patient received topical anesthesia with 10% lidocaine oral spray and instillation of 1% lignocaine solution directly into the tracheobronchial tree during bronchoscopy procedure. The delivery catheter of the vascular plug was introduced through the working channel of the bronchoscope to the anterior segment of the right upper lobe. The 6 mm x 7 mm size of the vascular plug was decided in accordance with the diameter of the bronchial stump and the length of the fistula with the aim that the vascular plug would fit inside the stump. The vascular plug was placed under both direct vision and fluoroscopic guidance. Following its placement, a dynamic bronchogram was performed to check the position of the vascular plug. Postprocedure, the patient was sedated and was put on cough suppressants to prevent displacement of the vascular plug due to coughing. Major air leak stopped and lung expansion increased on chest X-ray. However, small air leaks (APF) persisted, in spite of 4 weeks of infection control with parenteral and intrapleural antibiotics. It was then decided to attempt the fistula closure by administering diluted fibrin glue directly via the chest tube.^[2,4,5] Two Tisseel™ prefilled syringes were used for this purpose. The syringe comes with two components: a sealer protein solution containing fibrinogen and a synthetic aprotinin (fibrinolysis inhibitor) and a second solution containing thrombin.^[6] Ten milliliters each of sealer protein and thrombin solution were poured in two different sterile cups and were diluted with 30 ml of normal saline. First, diluted sealer protein solution was infused into the pleural space followed by the thrombin solution through the chest tube. Thereafter, the chest tube was clamped. The patient was instructed to rotate for a few times when the chest tube was clamped. The clamp was removed after 15 min. The chest tube was removed post procedure^[2] on the same day. The patient was ambulant and relatively symptom free post procedure. Radiologically, there was no further lung collapse and pleural space was nearly obliterated [Figure 5]. He was advised to continue on ATT for long duration (9-12 months) and was advised deep breathing exercises.