Successful Recanalization of a Complete Left Mainstem Bronchus Occlusion Using Fluoroscopic, Contrast-Assisted Guidewire Placement With Bronchoscopic Airway Balloon Dilation in a Patient With GPA
Endobronchial involvement in granulomatosis with polyangiitis (GPA) can develop in 55% of patients commonly as tracheobronchitis and rarely as bronchial stenosis.1,2 In these patients, the objective is to maintain intraluminal patency; whereby, endoscopic interventions should be considered. We recently evaluated a patient with GPA on immunosuppressive therapy who developed a left main bronchus (LMB) occlusion that was successfully recanalized using a combined fluoroscopic wire-assisted and bronchoscopic approach, which has not been previously reported. In patients with GPA who have tracheobronchial disease, this approach could be a safe and effective option when initial bronchoscopic approaches have been unsuccessful.
Endobronchial involvement in granulomatosis with polyangiitis (GPA) can develop in 55% of patients commonly as tracheobronchitis and rarely as bronchial stenosis.1,2 In these patients, the objective is to maintain intraluminal patency; whereby, endoscopic interventions should be considered. We recently evaluated a patient with GPA on immunosuppressive therapy that developed a left main bronchus (LMB) occlusion that was successfully recanalized using a combined fluoroscopic wire-assisted and bronchoscopic approach.
A 43-year-old Hispanic man presented to the emergency department with a 2-day history of dyspnea that accelerated over the past 24 hours. His medical history is significant for GPA and associated tracheobronchial stenosis which has been controlled with azathioprine 2 mg/kg/day, prednisone 18 mg/day, rituximab IV every 6 months and close bronchoscopic surveillance. His GPA was initially diagnosed 2 years ago following a presentation of alveolar hemorrhage where he received pulse corticosteroids and cyclophosphamide (600 mg/m2 every 3–4 weeks for four doses). His initial bronchoscopy was performed 1 year ago demonstrating scarring of the main carina and narrowing of both right and left mainstem and segmental airways. Since then, surveillance bronchoscopies have been performed every 8–16 weeks with concomitant airway balloon dilation and steroid injection (Kenalog 40 mg prepared in 10 mL saline with 3 mL of this solution injected in different quadrants to the affected area). His last bronchoscopy was performed 3 months prior to this presentation demonstrating stable disease. On examination, he was in respiratory distress requiring 60% fraction inspired oxygen at 50 L/min and had diminished air entry in the left hemithorax by auscultation. CXR showed near opacification of the left hemithorax (Fig. 1) and chest CT demonstrated greater than 50% stenosis in the LMB. Under direct bronchoscopic visualization, the LMB was completely occluded with scar tissue. Despite multiple attempts, we were unable to pass through the LMB occlusion. After a multidisciplinary discussion with interventional radiology and thoracic surgery, we decided to re-attempt recanalization using a wire-assisted approach with fluoroscopic and contrast guidance in our hybrid OR/IR suite.
The combined procedure was performed under general anesthesia. The LMB occlusion was reconfirmed with bronchoscopy. Initial passage across the occlusion was accomplished using a regular 0.035″/150 cm hydrophilic guidewire; however, following injection of contrast (3 mL Isovue-250) there was concern for false passage into the mediastinum (Fig. 2). The instrument was retracted and a 5-F SOS Omni selective catheter with a soft non-traumatic tip was advanced through the occlusion that allowed for a more cephalad direction of the guidewire. Injection of contrast confirmed intraluminal position within the lower lobe bronchi. Over this wire, serial 2-minute dilations were performed with a 6 mm × 4 cm, 8 mm × 4 cm and 10 mm × 4 cm angioplasty balloon with fluoroscopic guidance. After dilation, the bronchoscope was able to pass through the LMB (Fig. 3). Suction and lavage were performed in the distal airway segments with aspiration of copious secretions. The patient was successfully extubated and there was immediate improvement in his symptoms.