Airway complications after isolated lung transplantation

Airway Complications Transplantation

After Isolated

Lung

Wickii T. Vigneswaran, Pranya SakQalak, Sangeeta Bhorade, and Mamdouh Bakhos Bronchial complication remains a significant cause of morbidity after lung transplantation. Ischemia, infection, and rejection are important predisposing factors in the development of this complication. The reported incidence of this complication greatly varies among institutions, and controversy still exists as to the best surgical technique to minimize the incidence. Donor selection, preservation technique, and recipient management are likely important factors when deciding on the surgical technique. Complete dehiscence of an anastomosis is a rare event but usually requires a surgicalrevision and frequently is fatal. Partial bronchial dehiscence, stenosis, malacia, and obstructing granulation tissue or tumor can usually be managed with endoscopic techniques by using laser resection or cryoablation with or without stent placement in addition to treatment of associated rejection and infection. The overall incidence of post-lung transplant bronchial complication has declined over the years. Future advances in the donor preservation and recipient management of subclinical rejection and infection are likely to further reduce this significant morbidity after isolated lung transplantation. o 2002 Elsevier Science (USA). All rights reserved.

ronchial complication has plagued lung transplantation from the beginning. A tremendous amount of obsct-\ation made in the early part of the development of lung transplantation has given a lot of insight into the understanding of bronchial healing after transplantation. This hashelped to develop strategies to minimize posttransplantation complications. Early animal studies showed that a tine network of arterial channelsdevelopsand extends from the proximal cut endsof proximal bronchial arteries within 3 weeks of reimplantation of an autograft. This network was well shown, and by about 4 to 6 weeks, a bronchial circulation was re-establishedto a level comparable with the preimplantation anatomy.t:J Further studies showed that a radical hilar striping with division and reanastomosisof the distal bronchus showed bronchoscopic evidence of impaired circulation in the bronchial mucosadistal to the anastomosis.These changes disappeared in majority of the experiments by the 6th week.” Siegelmanet art showedfor the first time the regen-

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and Cardioanrctrlar

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Lk/~ar/nretrl 0J ilh~dicittc. &solo Uttitzrei~ Medical Ce~tter and Slrilclt .Scltwl oJ‘.Wdicitte, Lqola Lhtiuersi!y, Clticago, IL. rlddres tz/tritt/ rcqwts IO Wickii T. I’igttemaran, MB, IX, I;RC2S(CTlt), FRCSC. KKS, Deparheul OJ‘Tltoracic attd Cardiovascular Surgey, Lqla titriuxsi& Aledical Cettlrr, 2IGO South First Aw, II& rcmd, IL 60153. 0 2002’ I2mier Sciettrc (‘USA). 0955~47OX/OYIGO?-0002&?5.00/0 doi:lO. 1053llm-7002.

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cration of bronchial arteries after lung allograft transplant. The animals were immunosuppressed with azathioprine, prednisone,and antithymocyte serum. They observed a “sparse network of vessels extending just beyond the anastomosisby 12th day, which had extended into an abundant network of bronchial arteries well beyond the bronchial anastomosisby clay3 I .“.‘A key additional observation made in these experiments was the lack of correlation between the presenceof bronchial artery regeneration and the occurrence of bronchial necrosis.Some animals had no evidence of bronchial necrosisdespite a lack of bronchial artery regeneration, whereas others developed bronchial necrosisin the presence of bronchial artery regeneration. This showed the more powerful impact of rejection and immunosuppressionon bronchial healing. Barman et aI5showed much of the distal main and bronchial blood flow in the lung arisesfrom the pulmonary circulation. Lima et al” from Toronto studied the effects of steroids and azothiaprine on bronchial healing. After allotransplantation, they showed .markedly reduced bronchial anastomotic strength in dogstreated with steroids. Steroid-treated animals also showeda disorganized collagen pattern on scanningelectron micrographs at the anastomosis.These changeswere not observedin studies using cyclosporin for immunosuppression.f5*7 Their conclusionwas that the combination of early ischemic period, prednisone therapy, and rejection produced a serious risk for bronchial healing. The investigators, being con-

P’ol IG, No 2 (April),

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cerncd with the early ischmic pcriocl (ie, I-14 days), reported the USC of an omcntal peclicle wrap to buttress the bronchial anastomosis. The): showccl revascularization OF the anastomosis from Ihe omental wrap by clay 4.8J These observations suggcstcd Ihal al?er lung transplantation succcssf~~l healing could be promoted despite severance of the bronchial arterial supply. All the experimental work showed that lhe bronchial arlcrial nccwork is usually re-eslablished by the third week, and Ihe anastomotic dehiscence observed beyond this period appears to be more related to rejection and immunosupression than ischemia. However, the anastomotic stenosis obsen~ecl beyoncl this periocl may be partly an elrccl of the early ischeniia before bronchial artery regeneration. After the lirsl human lung Lransplanlation pcrIbrmed by Hardy in 1963, 3 I more (ransplants \vcre perlbrmecl worlclwide until 1978. T\\wty patients survived for more than I \vcck, ancl I6 of thcsc clevclopecl signilicant ain\,ay complications. Ischcniia \vas considerccl Lhc most important Factor contributing to the complications. The precarious nature of the donor bronchial arterial circulalion thcr&re lecl to the heart-lung Iransplanlalion as the trcalmcnt of choice for end-stage lun, m cliscasc. In this moclcl, an aclecluale t racheobronchial circulation \\.as olxc~~~cl l’rom the coronal?. to bronchial collaterals. The \\icle experience gained rrom the use of c)closporin in heart Iransplanlation, bronchial omeiilopcs)from the animal espcrimcnts, and juclicious LISC ofperioperativc corticosteroicl therapy clirrctccl the Toronto Lung Transplant Group to pcrlorm isolatecl lung transplants with improvecl bronchial healing. After a series of unsuccessful altcmpls, the first succcss~ul human single lung transplanl was pcrrormecl by the Toronto Lung Transplant Group in 19% 1 The success renewed interest in isolalecl lung transplantation arouncl the worlcl. Although the use or bronchial omenlopesy and avoiclance of high-dose perioperative corticosteroicls were thought to be kc). strategies For the lirst succcssrul series of human lung transplant, Schafers et all’ ancl Calhoon ct al’:{ reporlccl a telescoping technique for the bronchial anasloniosis without any wrapping. In the firs1 22 patients, there was no bronchial complication observed \vith this technique. In some or these patients, the high preoperative corticosteroids doses \verc continued through the transplant. The previous observation by Barman et al,” who showed that much of’ the distal main and lobar bronchial flow arises From chc pulmonary circulalion, was reinrorcccl by these results.

Further stuclics both in animal models and clinical sclting conlirmcd that omcnlopcsy is not essential, ancl modest early closes orcorticoslcroids do not impair bronchial healing. ‘-‘-w With this knowlcclgc, the practice or bronchial omenlopes); was cliscontinuecl, clccrcasing the operating time and the adclitionnl pain and ilcus or Lhc laparotomy. Subsequently, rcports li-olll other lung lransplanl groups suggeslccl that the telescoping technique crcatcs an obstructing Range or invaginatecl cartilage. This obs(rucling Range could harbor inrcction and promote pro~rucling granulation tissue formation wilh bronchial obstruction. Further modification to the technique was proposed by Griffith et alI7 to minimize the obstructing flange. Although the Carl!. clehisccncc rate hncl significantI!. rcclucccl by lhis (inic, lhcrc \vas still serious concern about lalc s(cnosis. This \\.as thought to bc bccausc of carI!. ischcmic ii!jui>.; ihcr&rc, it appearecl logical lo consiclcr clirccl bronchial arlq rc\~ascularizalion. Dirccl bronchial arterial rc\.ascularisalion \\‘as first clcscribccl b)f i\Ic(ras.‘>’ Mills et al,“’ in lhcir clog lung Lransplan( moclcl, observecl bcltcr anastomotic healing artcr clircct rc\ascularization. Daly et aI”’ rcintroclucccl this concept b) anastoniosing the bronchial nrtciy lo the internal nianiniai~~ arter-)’ in isolalccl lung lransplanl ancl Coumud et aI”’ in their double lung (ramplants. The proceclurc rccluircs aclclilional tinic ancl requires microsurgical arterial anastomosis. A subsequent reporl liom lhc sanic institulion rcporling on a ranclomizccl slucly lhilcd to she\\, a rccluction in ihc bronchial complication artcr clirccl rc\.ascularizalion.2z Unsatisraciol? clonor lung lwescrvalion resulting in significant rclmfusion injui7’, less sophisticatccl immuiiosLil~l~ressioii, ancl monitoring with unclclectecl rejection ancl lack of souncl knowlcclgc 01‘ bronchial circulalion \vas a major contributor dthc earl!. bronchial complications obscnwl with lung transplantation. These I‘aclors ~~ncloubtccll~ contributecl to the ischemia of the alreacly vulncrablc bronchial anastomosis. Although (cchniclues of bronchial anasComosis were c\&ing, significanl improvc.mcnt in clonor organ presciva~ion ancl rccipicn L managcmerit had been taking place in parallel. These developmenls made significant lxogrcss in reclucing reperfusion injuiy ancl in the early dclcction d- rcjection ancl ii;rection. All lhese ractors collectiveI) rccluce the bronchial ischcmia ancl facilitate anaslomolic healing. I’ulmona~~~ vasodilators and lung inflation uncloubtcclly improvccl dislribulion or the colt1 pulmonary fl~~sh in the donor lung cluring preserva-

Telescoping

Simple Interrupted

lion, and allograli h~pothcrmia is ~urthcr maintainrcl I~\, topical rolcl cluring the implantation recluring the warm ischcmic time.“:‘-‘“’ These steps cerlainl!~ rcclucecl the clcgrcc and inciclcnce of rcperlilsion injm-). ancl have improvccl grali limction al’tc1 11~ansplanlation. Routine use of‘ bronchoscopic survcillancc with biopsy and lavage hacl l~crniittecl earl) and precise cliqgnosis and treatment of‘ allqgrali clyslimction.~i l’ulmonat~ lo bronchial arterial collateral circulalion improved with reduction in repcrrusion injuty ancl rejcclion. I&ping the bronchial slump shorl ancl using meticulous anaslomotic technique I1rlhcr reclucecl the ischemic bronchial segment and I‘acilitalccl bronchial healing. Various lcchniqucs of bronchial anastomosis have been clcscribecl (Fig I). It is universally acceptccl that a conlinuous suture technique Ibr the membranous portion of the bronchus produces very satislactory healing. The preferred technique for anaslomosis 01‘ the cartilaginous part of the bronchus remains controversial. The telescoping tcchniquc, which was in vogue Ibr a lime, has been replacccl slowly in may centers by nonlelescoping encl-lo-end anastomosis when there is no significant mismatch between lhc recipient ancl donor bronchus six. A technique 01’ cncl-lo-end, simple, vertical, interrupted suturing 01 a Ligure-8 sulure for the cartilaginous bronchus is usecl. Thcrc are no ranclomizecl studies showing an advantage or one technique over the olhcr, but a lower incidence of complications has been reported with the encl-to-end technique compared with a telescoping technique.‘“-:” Generally, a monofilament absorbable suture material is used Ibr the bronchial

Figure of Eight

anaslomosis brcausc this has been sho\\n to cause Ic’ss inciclcncc 0Tgranulation tissue rormation al the silt.

Type of Bronchial Pathology The bronchial complication or the major airwa!*s can alTcc1 the site anaslomosis or lhe proximal don01 bronchus. Brcakclo\vn or the bronchial anastomosis with complcle clchiscence is an uncommon complication. This is usually an earl!; postoperative complication but has been reported years arter transplantalion. Partial dchisccnce is perhaps more common than is reported. Complcte or partial dehiscence can lead to inkction ancl abscess rormation and mcdiastinitis. The clegree of‘ bronchopleural tistula is variable li-om pneumothorax to torrential air leak, which may rccluire emergent surgical intenw~tion. Bronchial obstruction may manifest in the Torn1 of stenosis or bronchomalacia or as an obstructing lesion or protruding granulation tissue or tumor. By Tar, the commonesl airway complicalion alicr transplantation is bronchial stenosis. This is twice as co1nmon as malacia, but both may coesist. Bronchomalacia can all‘cct not only the anastomotic site but also the distal ainva),. Pseudomembranous bronchitis may complicate the stenosis, because of either excessive intrahnminal debris or inflammation. Occasionally, pseudomembranous bronchitis by itselr can cause ainvay obstruction, usually early arter transplanla(ion, 1~~11has been reported late, if there is a signiricant amount of intraluminal clebris associated with the bronchitis. This appears to be connnoner in pa-

d

90

Vigneswaran

tients with cystic fibrosis. The offending organisms are usually Pseudomonas 4, Staphylococcus aureus, and 31-33A strong correlation between Asp~gillllrJumigatus. the presence ofAspergil1~ and the subsequent occurrence of airway complications has been reported. Inflammation process caused by local infection with Aspergillur may contribute lo the airway narrowing. Whether A.spergillus infection is present as a consequence of ischemic necrosis or whether it causes necrosis by itself is difficult to know because there is a frequent coincidence of both factors. However, when bronchial necrosis was described at the first postoperative bronchoscopy together with Ll+!~e?&$~us infection, the incidence of later airway complications was reported to be higher than if there was necrosis alone. It is, therefore, likely that AS/X$~ZIJ plays a direct role in the development of airway complication. Posttransplant lymphoproliferative disorder has been reported as a rare cause of airway obstruction.

el al

ated and treated appropriately, and a repeat examination is warranted in these circumstances. The major ailway dehiscence occurs within the first few weeks after transplantation, and an early sulveillance bronchoscopy is useful in the detection. A significant ailway obstruction is delined when the luminal narrowing is greater than 50%. A fiber-optic bronchoscope with its wide-angle lens can deceptively enlarge the apparent size of the lumen, and therefore, when in doubt, a direct examination with a rigid bronchoscope would be advisable. Bronchomalacia causes a dynamic expiratory collapse, which can be overlooked unless the examination is performed while the patient is breathing spontaneously. Evaluation of the airway narrowing should document the location, length, and caliber of the stenosis and the presence of granulation tissue, retained secretion, and distal bronchitis or pneumonia.

Management Diagnosis An airway complication can present with symptoms and signs that are nonspecific such as cough, dyspnea, or wheezing. Other nonspecific findings that may give a clue to airway complication are radiologic abnormalities such as infiltrates or volume loss and finding of airflow obstruction in the flow volume loop of spirometry. Spirometric findings cannot distinguish airflow obstruction caused by rejection from anastomotic stenosis. The findings can be sometimes confusing in a patient with single lung transplant with the airflow obstruction in the native lung. In general, an unexplained decrease in the forced expiratory volume in 1 second or a plateau of the expiratory limb of the forced volume loop that is consistent with airflow obstruction is suggestive of an airway stenosis.34J” Computed tomography can be useful in the diagnosis of a disrupted airway, and extraluminal or mediastinal air collections are ob served or there is a peribronchial collection of fluid indicating abscess formation.“” Computed tomography is useful in bronchomalacia if a dynamic study of the area could be performed or facilities exist for virtual bronchoscopic examination. Bronchoscopy is the key diagnostic procedure. Early examination of bronchial abnormality of mucosal pallor, darkened mucosal area of ischemic necrosis, and edema or slough could proceed to heal without complications in the majority of the instances. Nonetheless, the finding of an opportunistic infections or evidence of rejection should be evalu-

of Airway

Complications

Bronchial Dehiscence Significant necrosis of the graft ailways can occur up to the point of anastomotic dehiscence with subsequent bronchopleural fstula, mediastinitis, or erosion of vascular structures. When dehiscence involves the cartilaginous portion of the anastomosis, there is an increased risk of stenosis in that airway as it heals. Most major bronchial dehiscence is adequately drained into the airway at the time of the first presentation. Sign&ant dehiscence-associated pneumothorax, atelectasis with obstructive pneumonia, or pneumomediastinum should be managed expectantly. The lirst treatment is adequate drainage by a pleural or mediastinal tube. If the lung remains completely expanded with adequate drainage, the leak should seal, and the airway may heal without significant stenosis. A covered self-expanding stent sized appropriately can facilitate the healing process. Successful management of partial dehiscence had been reported by serial application of platelet-derived growth factor in combination with laser.37 A dehiscence associated with massive air leak or failure to expand the lung with chest tube and endobronchial intervention will require early surgical intervention. If necrosis is strictly confined to the proximal donor’s main bronchus, resection of the necrosed segment and reanastomosis should be attempted.‘” Reinforcement of the anastomosis with vascularized tissue should be performecl to enhance healing. If the distal airway of the donor lung is nonviable or of questionable viability, retransplanta-

91

Lion remains the only option. In a patient with bilateral hmg transplantation, when a unilateral dehiscence shows distal ainvay necrosis and no course for salvage or that donor lung, an ipsilateral pneumonectomy would be an option and has been wxl successfully in selected cases.

Airway Obstruction Airway obstruction in lung transplantation recipients may manifcsl in the form of stenosis, malacia, or endobronchial obstruction by granulation tissue or tumor. When the stenosis is tight, retained sccrction and mucus can worsen the obstruction and predispost the patient to postobstructive pneumonia. Chronic bronchial stenosis sl~oulcl bc trcatcd when it causes sputum retention, cough, obstructive pneumonia, or cletcrioration in pulmonary function. Bronchial obstruction ma)’ bc associntccl with concurrcnl bronchial infection ancl/or rcjcction. Bronchoscolq woulcl be rccluirecl to inspect the airways to cvaluatc the clcgrce or obstruction ancl to diagnose associalecl inliction or rcjcction. When airway obstruction occurs in the setting of a concurrcnl episode or graft rcjcction or infection, approprialc therapy directed toward these will enhance the resolution or the airway obstruction. Intensification of the immunosuppression regimen or i&itulion of appropriate antimicrobial therapy can result in the reversal or bronchial stenosis without a mechanical intcrvention.:“’ Beyoncl the treatment of the associated inl’cclion or grali rejection, the management of large airway obstruction often requires mechanical intervcntion. A stenosis is first dilatccl. Initially, a flcsiblc bronchoscopc ancl balloon clilatation may adequatcl) open up the stenosis. It is not unusual to require more tlxu~ one dilatation. When the stenosis is resistant to balloon clilatation, rigicl bronchoscopy with general ancsthcsia and clirect dilatation with bougies may be requirccl. Rigid bronchoscopy proviclcs a larger arca through which stiKer dilators can bc usccl. In aclclition, it also proviclcs a sccurc airway and gives better control in the event of untoward complications such as hemorrhage. Repcatecl and frecluent clilatation will often maintain aclequalc ainvay until a granulation stricture is coverecl by epithelium. Eidobronchial stents should bc used when rcpeatecl clilatalion fails to maintain aclecluate lumen. There has been a lot of experience with silicone elastomer, silicone, and metallic stents in the litcrature.“+” The sell-expancling, metallic stents arc a late arrival on the scene, and therefore the early cspcrience is mainly with silicone elastomer and

silicone stents. The silicone elastomer or silicbne stent requires a rigid bronchoscope for deployment. Proper placement or the stent is confirmed by flexible bronchoscopy. Silicone stents have the disadvantage of a narrow lumen, interference with the clearance of airway secretions, and tendency to disloclge. Granulation tissue growing around the end of the stent may also cause aiway obstruction. Mucus plugging is avoicled by daily use of N-acetylcysteine or isotonic sodium chloriclc inhalation. Granulation tissue can be treated by laser coagulation. Stents placed for bronchial stricture are usually required only temporarily. After scvcral months, the aitway seems to obtain a degree of rigidity without the stent in place. Therefore the greatest advantage of the silicone or the silicone elastomer stents is that they can be removecl easily once the stenosis is stabilized. These stents, however, have a higher tendency to disI0 d gc. :I” The use of self-espanding, metallic stents as an endobronchial prosthesis has several advantages over silicone stents. The insertion technique is relatively simple and does not require specialized delivcry devices. The stent is highly visible under lluoroscopy, and therefore deployment and follow-up of the stent are easy. The stent can be expandecl to varying diameters either during initial placement or at a later date. The ultimate diameter of the stent is controlled by balloon dilation. Expandable, metallic stcnts are used increasingly Ibr bronchial stricture because of these advantages. They are less bulky than silicone stents, exert a greater radial force, are less likely to clislodge, and allow better clearance of ainvay secretions. The major disadvantage is that once they are deployed they are diflicult to remove. Rarely, a stracldling seconcl stent is required to treat stenosis that develops at follow-up. When protrucling granulation tissue is the cause orainvay obstruction, the initial treatment would be either laser or ciyotherapy Lo remove the granulation tissue.,‘1--‘3 The need for adjunctive clilation and ultimate stent placement appears to be related to the clegree orfixecl obstruction caused by fibrosis and can bc determined readily after ;he removal of the granulation tissue. Posttransplant lymphoproliferative disease has also been reportecl as a cause of airway obstruction and can be treated by reducing immunosuppression. If there is no response, chemotherapy shoulcl be consiclered.+l,J” Surgical approaches such as sleeve resection, lobectomy, and retransplantation should be reserved only for selected caSes when all other procedures have failed.

Loyola Experience The lung transplantation program at Loyola Univcrsily hkclical Ccnler, Chicago, IL, was iniliatccl in 1986. The initial lung transplantations wcrc heartlung blocks and double-lung transplantation. The lirsl isolated single-lung transplantation \\3s pcrformecl in 1991. Scvcral changes have afTeclccl the program since then. Among them wcrc major clono~ issues resulting in extending the selection criteria, surgical lechniqucs, posloperali\~c care, ancl nc\veI immunosul,prcssion lherapics including lhc use of induclion lhcrap~~ wilh a humanizccl monoclonal antibody thal is an inlerleukin 2 rcccplor nntagonisl. For lhe purpose of this article, \vc rc\kvccl our cspcricncc of isolatccl lung lransplanlalion lxlwccn I991 and 2000. During lhis pcriocl, 151) single lung 1ransplanLalions and I36 bilaleral squcnlial lung lransplantations wcrc performccl. Of the I50 single lung transplanls, 77 lvcrc righl single-lung lransplants ancl 73 \vcrc lcli single-lung lransplants. Thcrclbrc 422 bronchial anaslomoscs \vcrc al risk for clcwloping complications. Or lhcsc, 2 13 \verc righl-siclcd anaslomoses ancl 209 were Icfi-siclccl anastomoses. Three distinct anastomotic tcchniclucs were used in these patirnls by 8 surgeons during lhesc 10 years (Fig I). One hunclrecl sisly-tight palicnls unclenvenl anastomosis with a lclcscoping lcchnique, I81 with a simple inlcrruplccl sulurc lcchnic~uc, ancl 73 will1 a ligure-8 lcchniquc Ibr the cartilaginous part or the bronchus. All patients unclerwenl a conlinuous suture I‘or lhe menilxanous part of the bronchus. A monolilament alxorl~al~le suture material was usecl for lhc Iwonchial anaslomosis in the majority ol’ cases. In the early cxperiexe, nonalxorhable monofilament sutures \vere used Ibr Ixonchial anaslomosis. We retrospeclivel) reviewed all clinically significant I~ronchial complicalions olxcrvecl in lhis cohort or palicnls. Filiy-two bronchial complications devclopecl ( 12.3%) in 43 patients (15%). There were 20 men and 23 women in this group with a mean age of 44.7 years (range, 18-67 years). Twenty-six patients had received a hilaleral sequential single-lung transplanl, ancl Ii paticnls hacl receivecl a single-lung lransplanl. Of the 26 lilalcral lransplanls, complicalions developed on both bronchial anastomoses in 9 and only on 1 side in 17. Complications clevelopecl in I6 of the 213 rightsided anastomoses and in 36 ol’ the 209 lert-sided anastomoses. This diKerence \vas statistically significanl (I’ < .005). Twenty lelescopic anaslomoscs (I I .9%), 24 simple interruptecl anastomoses ( l3.3%),

ancl 8 figure-8 anaslomoses ( 10.9 %) were associalccl with complications. A statistically significant cliffcrcncc in the rate of bronchial coniplicalion was ohscrvccl among surgeons pcrrorming lhc lransplanlalion, regarclless of the anastomotic technique. This inciclcncc \.ariecl Ixtwccn 8% ancl 33%. The ycarl) coniplicalion ralc cluring lhc slucly pcriocl \wiccl hct~~uzn 2.5% ancl 22 “/o each year; howc\.er, this hacl rcmainctl arouncl 10% cluring lhc lasl 4 years of lhc review \+itli a slcacl!~ clcclinc in the inciclcncc rn’cr time. The Icngth of the clonor ischcmic pcriocl or the inslitulion OF carcliol)Llltiiolia17. h!pass li)r lhc lransplantation clicl no1 sho\v any corrclalion \vilh the bronchial complications. Analysis of palicnls Ivho unclcnvcnl a hilalcral lung lransplanl ancl liacl oncsiclccl complication clicl no1 show any clilTwcncc as lo whcthcr the all‘eclccl sick \\‘iis lransl~lanlccl lirst 01 scconcl. The conil~licalions \vcrc olxc~-\~ccl as Carl!. as 2 \vcclis ancl as lalc as 4 years. The median periocl 01 the clc~clol~mcnt\\xs -I5 cla)~ ~~osllrans~~lanlalion, ancl lhe peak inciclence was I~cl\vccn I and 3 monllis. Seventy-three pcrccnt 01‘ all complications \verc ohserved wilhin lhc lirsl 6 months. Three palicnls ( I .O+%) cliecl as a clirecl rcsull of the complications al 15, 57, ancl 120 clays, respcclivcly. One palienl was relurnecl lo the opcraling room I‘or revision or lhc anastomosis. Ten of the anastomotic complications \vcrc mana,qecl with clilalalion lvilh or wilhoul Iawl resections, ancl the remaining patients wcrc‘ managecl wilh clilalalion ancl a slenl placcmcnt. During the study period, many l)pcs o~slcnls \vcrc cleployecl, parlly Ixcause of the c\dulion on lhe slenl tcchnoloa and partly hccausc of lhc analoni), of lhr slcnosis (Table I). The \rast majorit!. of them wcrc PcrmaIumc-coverccl wall slcnts (Boston Scientific, Maple Grove, MN). In 3 of lhc bronchial anaslomoscs, a sulxequent re\ision of the prcviousl). cleplo~~ccl slcnt \\‘as recluirccl, ancl in 4 instances, an aclclilional stcnt was placccl cluring the ~ollo\v-~~l~

Table 1. Type and Thcrapcutir Intcnw~tions CXnically Signikuil Bronchial Ck~mplications

fw

Conclusions We

liavc

olxaxd

cliial

comldications

ation

of

llic lung lo note

extending

the donor donor

last

institution

hat

this

for

t7 The

rclatecl

to meticulous of ncwcr

crileria

It1 With

lxcser\.alion

tcclinic~ucs,

ment

or subclinical

rejection

a continuing

assorialccl lalecl

uilli

lung

tcchnicpc the

acloption

detection, ancl

in

tlic

Inui

k

Srldcrs

cwluation

tcchnicluc.

of 1hc

cc~rlicostcroid

.J ‘l‘horac

role

or omcn1u

zdminis1~alion

‘l’horac

I-IJ, Aoki hing

Cartlio\asc

M, ct al: Bronchial

1lansplnn1n1ion:

The

ion ol~prcclnisonr.~J

.JS. ~Jrr~nn;~ntl;~rn

chial

IHding

lirm.

Ann

in

Surg

1993,

Thorac

circulation ClkCl

af1c1

or long-1crm

Carcliovasc

BP,

MIS

liolx

Surg

1993,

SL,

pwlinii~~airr

Buycl

Surg

sur Sri

C:artlitr\~;rsc~

la grcni.

l!)50,

pil-

Surg

I 99-l,

Mu). Ghcrm~lxmg

S, Id 1.i~4 i.mi

Il.iltisl~lil1ilillioII

\villi

clircc-1

Surg

1993.

Tlicw;~

L. Badc1

1iw

Ixudlid

willi

l!lW.

ul

.J Thornc

Ck-

1iO:XM

lung:

Ann

signilicnncc

11-;~nsl~l;~tl1;l1ion.

RCA Tadjknrimi

C:ourautl

clu pmm”

C:, CI al: The

in luy

IWO,

loldr

23 I: I I76

Daly izalkm.

21.

Bron-

lrai~sl~limlik

IF. CI al: Anastomotir

,J Tlwac

C: R i\cacl

circul;11ion

cliotasc

References

Grmzalcz

1r;lnsl,l;ln1;l1ion.

Iv chitm.

lwunchial 20.

lung

19.91, 53:XIl

\!J,

I-I: SuIr

I!). .\lills

translkmtation.

et al: ~Kormal

in rmlinr

I

AIclr;~s dwz

iso-

wrapping

Surg

~lqw

in lut~q

lOi: IX.

V, Sanrhcz.J.A,

\~\‘i1lwm Thorac

17. Grillith

treat-

after

A. An

lwiol~cralivc rr;rnspl;~nt;~tic,n.J

aclminis1ra1

nncl

niorbiclit~~

complications

lung

16. Autc:ri

intro-

wc

early

mntl

IO5:47-I

of hcttct

infiiction,

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I-II. c1 al: I’ros1;qdin

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airway

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au1ugralis

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XI. ~1 al: Sucrcsslid I~ronclii;d

of ltmg

49: I03 I

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in hc~1-lung

bclwrcm

2X.

CI al: Amclicrrarirm

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I-IJ, I~;r1n1rl~~tll1;1~n

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01‘

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Ann

m;l”:qr”lr”l.

chid

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I.e\.ilsct1lnl.i%ilIio1i

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Thtr;~c

Surg

Yaltlnt~cli

IW-I,

V. Laghi

JAI.

hlrNril

Surg

.ii:

lkly

and

1997,

IillC

Inciclcncc

63: I.576

in~nwclinl~

tlirwr

lmm-

1ranspli~~~t;~1io~l.

l+l6 ;dirr

lung

Irn1isl~la1ilalion.

X:21)7

I:, .\lrC:alx

KD.

cl al:

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I’: Ink~1kms

I-Irnl-1

kll,

tl.il1lsl~l;l1l1;llio11:

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hrh IW.

t~;lsl~lan1;~1ion..J I-Icrrrr;~

CGA:

IL, \Villiams Rrspir

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Srniin

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.\lr\,

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lSll.5, ct al: Ainvay

and

lung

IkXX3 romplica-

94

Vipmaran

tions after lung transplantation: outcome. Ann Thorac Surg 2001, 34. Gelb

Al;‘, Zamel

N, Colchen

tracheobronchial stents Dis 1992, 146: 1088

Treatment 71:989

and

long-term

A, et al: Physiological

in airway

obstruction.

studies

01

Am Rev Respir

35. Anzueto A, Levine Sh4,Tillis WP, CI al: USC or the flowvolumc loop in the diagnosis of bronchial stenosis after single lung transplantation. 36. Schleutcr

Chest

1994,

PJ, Semenkovich

105:993+ JW,

Glazer

I-IS, et al: Bronchial

clehisccncc after lung Lransplantalion: fndings with clinical outcome. Radioloo 37. Hertz Ml. photothcrapy struction

Harmon and aflcr

lung

RR. Knighton growth htctor

A corrclalion oT CT 1996, 199:849

DR, et al: Combined trcntmcnt of bronchial

transplantation.

Chest.

1991,

laser ob-

100: I71 7

38. Susanto I, Peters JI: Lr\ine S, CI al: USC OT bnlloon-espandable metallic stems in lhc nntngrn~rnl d bronchial stenosis and bronchomalacia alter lung transplantation. Chest 199X. I Id:1330 39. Colt HG, ~Jansscn .JP, Dumon .JP, et al: Endoscopic management of bronchial stenosis atier double lung trans~~lantntion. c:llcsl 1992, 102: IO 40. CoopcrJD, stents

Surg 4 I. Ionch!wt

Pearson

PG. Patterson

in the mnnagcmrm 1989, 47:37 I VA, Arcidi

JAI,

GA,

of’ ainvay Gnrrity

ct al: USC or silicone

problems.

Ann

RR. et al: Reli-actov

Thorac PJSI-

el al

lransplanl airway strictures: wire stcnts. EurJ Cardiothorac 4-2. Maiwand MO, Zehr RJ, Dyke

succcssruimanagement Surg 1999,15:H42 CM, et al: The role

with

ofct)other-

spy for ah-way complications alter lung and heart-lung transplantation. Eur J Carcliothorac Surg 1997, 12:5-1-g 43. Mndclen BP, Kumar I’, Sayer R, et al: Successful rcscction 01 obstructing aitway granulation tissue rollo\kg lung transplantation using endobronchial laser (1Ncl:YAG) therapy. J Cardiothoracic Surg 1997, 12:480 44. Garrett TJ, Chaclburn A, Barr AIL, et al: Posttransplantation I)mpho~~roliTerati~~c clisorclcrs dosorubicicn-\incristinc-prcclnisonc

trcatecl

Eur

with qclophosphamidechcmothcrapy. Cancel

45.

1993,72:27x2 Leblond V, Sutton L. Dorent R, et al: Lymphoprolifcrative clisorders alter organ transplantation: A report of 24 cases

-I&

obsetvrd in a single center. J Clin Oncol 1995, 13:9FI Montoya A, Alawulawclc k, Houck J, ct al: Loyola Lung Transplant TC~III. Sut~ival nncl limctit~m~l OUICO~~ slier single ancl

bilalcral -17. Bhorndr ization

lung lr~unsplnntalit111. Surgcty 199-1, I It%712 SA,l, Vigneswnran, W, A~lcCabe AM, et al: Libcralof Donor Criteria may cspancl the clonor pool without

adverse consccp~encc in lung tr;lnsplsnt;ltioi~. .J Heart Lung T.’I ‘msp Ian I 2000 , 19: I I99 -48. Garrity RR, Villanucvn~J, Bhoradc SAL, et al: Low rate orecute lung allogr:di rejection after the use d clnclizun~ab, leukin 2 rcccptor antibody. Transplantation 2001,

an intc7 I: 773