Endobronchial Protrusion of an Amplatzer Plug After Embolization of the Pulmonary Artery

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To the Editor:
Radiointerventional placement of vascular plug in the pulmonary artery is an invasive procedure that can be considered in patients suffering from massive hemoptysis linked to malignant bronchopulmonary arterial fistula (BPAF). BPAF is a rare complication of lung cancer,1 and effective treatment with amplatzer plug occlusion has only been reported once.2
A 62-year-old woman was admitted to our institution for the management of a severe malignant central airway obstruction involving the carina. This dramatic locoregional progression of a metastatic squamous cell carcinoma occurred during chemotherapy. The patient underwent airway stenting (Dumon Y Stent) but then presented acute respiratory distress due to massive hemoptysis. The systemic treatment (terlipressin) showed no results. After orotracheal intubation, a chest angio-computed tomographic-scan was performed, showing erosion of the posterior wall of the right pulmonary artery and blood inundation of right airways. This examination guided a radioembolization of the right pulmonary artery with a dedicated plug (Amplatzer Vascular Plug), resulting in an immediate control of bleeding. A flexible bronchoscopy performed 10 days after the procedure showed endobronchial protrusion of the distal end of the plug in the bronchus intermedius, with no evidence of blood in the airways (Fig. 1A). A computed tomographic scan confirmed the satisfactory complete occlusion of the pulmonary artery (no contrast extravasation), and the projection of the distal third of the plug through a large bronchovascular fistula, into the right main bronchus (Fig. 1B). The patient then received anti-programmed cell death 1 immunotherapy in a second-line setting, resulting in prolonged disease control.
This first description of endoscopic visualization of a vascular device testifies to the importance of the BPAF. The presence of interventional pulmonologists, critical care physiologists, and radiologists allowed rapid and efficient management of 2 successive life-threatening situations. As our patient is still alive 6 months later and actually responding to antitumor immunotherapy, this report suggests the interest of invasive treatments (interventional bronchoscopy, interventional radiology), even in a palliative context, as they can offer immediate palliation of symptoms and provide “gaps” to specific treatments. Rapid ventilator weaning after stent insertion for malignant central airway obstruction is possible in most of cases.3 Our report suggests that the same attitude should be adopted for the invasive radiologic management of severe hemoptysis.
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