Medical Image of the week: Endobronchial Valves

Figure 1. Bronchoscopic view of the endobronchial valves in the right upper lobe sub-segments.

Figure 2. Post procedural chest x-ray shows the valves (encircled). Other findings on this chest x-ray include a tracheostomy tube, right sided chest tube, left sided PICC line. Bilateral pneumatoceles are also seen (arrows).

A 39 year-old woman was referred to our hospital for evaluation of persistent broncho-pleural fistula after severe necrotizing streptococcal pneumonia. She had undergone a segmentectomy for the necrosis resulting in the broncho-pleural fistula. Her overall medical condition and malnutrition precluded another major surgery such as a muscle flap for the persistent air leak. Endobronchial valve placement was attempted to minimize the gradient and leak across the parenchymal defect to promote healing.

A sequential balloon occlusion technique was used to localize the leak to the right upper lobe, which was the site of the previous surgery. The sub-segments were measured and three endobronchial valves (Spiration®, Olympus Respiratory, USA) (1). Valves of 5 mm, 6 mm and 7 mm – were placed in the three sub-segments of the right upper lobe (Figure 1) with a flexible bronchoscope. Near elimination of the air leak was seen post procedure. Figure 2 shows post procedure chest x-ray showing the three valves.

Removable endobronchial valves have been shown to be safe and effective in cases of persistent post-operative air leaks (2).

Bhupinder Natt MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. Olympus Corporation. Spiration® valve system. Available at: http://www.spiration.com/us/product-overview (accessed 6/21/16).
2. Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, Musani AI, Kucharczuk JC, Gonzalez HX, Springmeyer SC. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011 Jan;91(1):270-3. [CrossRef] [PubMed]

Cite as: Natt B, Knepler J. Medical image of the week: endobronchial valves. Southwest J Pulm Crit Care. 2016;13(1):34-5. doi: http://dx.doi.org/10.13175/swjpcc057-16 PDF

Medical Image of the Week: Bronchial Artery Embolization

Figure 1. Thoracic CT with contrast demonstrating right upper and lower lobe tree-in-bud and ground glass opacities (arrows) consistent with progressing pulmonary coccidioidomycosis.

Figure 2. Chest radiograph demonstrates the ethylene vinyl alcohol polymer retained in the bronchial arteries after the embolization procedure (arrows).

A 25-year-old woman with a past medical history significant for pulmonary coccidioidomycosis and poorly controlled type I diabetes mellitus presented to the emergency department with a chief complaint of 4 days of progressively worsening shortness of breath and 3-4 days of intermittent hemoptysis. Initial CT scan demonstrated progressive tree-in-bud and ground glass opacities in the right upper and lower lung lobes suggesting worsening of her ongoing coccidiomycosis (Figure 1). On hospital day 3 she began to have worsening hypoxemia and hemoptysis requiring transfer to the intensive care unit. Interventional radiology was consulted who performed an emergent right sided bronchial artery embolization with the ethylene vinyl alcohol polymer, Onyx^tm. After embolization her chest radiographs demonstrated evidence of the embolization material in the pulmonary vasculature (Figure 2).

Ethylene vinyl alcohol polymer, Onyx^tm is a liquid embolic substance which solidifies after contact with ionic materials (1). This results in a rapid, irreversible and permanent embolization of the bleeding target vessel (2). It was initially approved for use in the embolization of cerebral arteriovenous malformations, however has been used for rapid embolization of other hemorrhagic conditions such has hemoptysis from bleeding bronchial arteries (3). The most common complication after embolization is chest pain that is self-limiting. Transverse myelitis from spinal cord ischemia is the most serious complication associated with bronchial artery embolization however the occurrence is significantly decreased by spinal arterial identification during initial angiography (4). This patient’s embolization was without complications. She was successfully extubated on hospital day 15 without evidence of ongoing hemoptysis and will continue to follow up in the pulmonary and infectious disease clinics for ongoing treatment of her Coccidiodes pulmonary disease.

Benjamin J. Jarrett MD, MPH and Sachin Chaudhary, MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

1. Lubarsky M, Ray C, Funaki B. Embolization agents-which one should be used when? Part 2: small-vessel embolization. Semin Intervent Radiol. 2010 Mar;27(1):99-104. [CrossRef] [PubMed]
2. Yamashita K, Taki W, Iwata H, Nakahara I, Nishi S, Sadato A, Matsumoto K, Kikuchi H. Characteristics of ethylene vinyl alcohol copolymer (EVAL) mixtures. AJNR Am J Neuroradiol. 1994 Jun;15(6):1103-5. [PubMed]
3. Guimaraes M, Wooster M. Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications. Semin Intervent Radiol. 2011 Sep;28(3):350-6. [CrossRef] [PubMed]
4. Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2011 Mar;28(1):48-62. [CrossRef] [PubMed]

Cite as: Jarrett BJ, Chaudhary S. Medical image of the week: bronchial artery embolization. Southwest J Pulm Crit Care. 2016;13(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc053-16 PDF