Management of bronchocutaneous fistulae using endobronchial valves

SESSION TITLE: Interventions for Cardiothoracic Abnormalities SESSION TYPE: Case Reports PRESENTED ON: 10/08/2023 10:45 am - 11:45 am INTRODUCTION: Broncho-cutaneous fistulae (BCF) are an uncommon and challenging problem. Management options include surgical repair and endoscopic interventions. Endobronchial valves (EBVs) are well-established for the treatment of bronchopleural fistulae and emphysema. We describe a case in which a patient with BCF's was managed using a hybrid approach of surgery and EBVs. CASE PRESENTATION: A 71-year-old woman developed a sternal infection after undergoing a redo CABG. The pectoralis flap failed due to BCF development (Image 1). A CT revealed a fistula tract to the sternal bed (Image 2). Given her complex surgical history and co-morbidities, we elected for a hybrid minimally invasive approach. After the flaps were taken down, the right middle lobe (RML) and right upper lobe (RUL) bronchi were each occluded, resulting in cessation of the air leaks from the fistulae. A 7 mm EBV (Olympus America Inc, Lombard, IL) was deployed to exclude the RML. Similarly, exclusion of the anterior segment of the RUL with a 6 mm Olympus EBV resolved the second fistula. The patient underwent primary closure of the fistulae and pectoralis flap revision a week later. The post-operative course was uncomplicated but she returned as an outpatient with evidence of infection and recurrence of her BCF. In the operating room, she underwent incision and drainage. The EBVs were removed, and purulent debris was aspirated from the bronchi distal to the EBVs. Next, an EBV with a Heimlich valve (Zephyr Valve; Pulmonx, Redwood CA), was placed into the RML orifice (Image 3) and one in each of the three upper lobe segmental bronchi, for a total of four EBVs. The patient has been followed as an outpatient without any evidence of ongoing infection. Her CT scan showed resolution of the fistulae three months later and the EBV's were removed with no evidence of recurrence of the fistulae. DISCUSSION: We describe a patient who developed BCF for whom extensive operative management was prohibitive. Patients with BCF present in various manners, often with recurrent chest wall infections. Our patient's flap failed due to the persistent fistulae. After the initial placement of EBVs, she developed a new fistula and a recurrent wound infection. We replaced the valves for a system with a Heimlich mechanism, allowing for better drainage from the distal bronchi while providing a one-way valve mechanism. When presented with BCF's, it is imperative to use a multi-modal approach, including treatment of any infection and definitive management of the fistula. Options include surgery, with takedown of the fistula, and endoscopic interventions. In patients with co-morbidities and complex surgical histories, surgery alone may be prohibitively risky. Using a hybrid approach with bronchoscopically placed EBV's in combination with local control of the chest infection and fistulae is a viable option that allowed us to avoid highly invasive surgery in our patient. CONCLUSIONS: Bronchocutaneous fistulae are rare problems and difficult to manage. EBVs are a successful option for intervention, especially in patients for whom surgical intervention would be highly morbid. REFERENCE #1: Valipour A, et al. Endobronchial Valve Therapy in Patients with Homogeneous Emphysema. Results from the IMPACT Study. American Journal of Respiratory and Critical Care Medicine. 2016; 194(9), 1073-1082 REFERENCE #2: John SK, Jacob S, Piskorowski T. Bronchocutaneous fistula after chest-tube placement: A rare complication of tube thoracostomy. Heart and Lung. 2005; 34(4), 279-281 REFERENCE #3: Gaspard D, Bartter T, Boujaoude Z, et al. Endobronchial valves for bronchopleural fistula: pitfalls and principles. Ther Adv Respir Dis. 2017;11:3–8. DISCLOSURES: No relevant relationships by Julia Coughlin No relevant relationships by Nicole Geissen Speaker/Speaker's Bureau relationship with medtronic Please note: 2021 to present Added 03/29/2023 by James Katsis, source=Web Response, value=Honoraria Consultant relationship with ion / intuitive Please note: 2020-2021 Added 03/29/2023 by James Katsis, source=Web Response, value=Consulting fee No relevant relationships by Audrey Pendleton No relevant relationships by Christopher Seder