IPBronch.com | Interventional Pulmonology

🎯 Background & Rationale

Persistent air leaks (PAL) and bronchopleural fistulas (BPF)—specifically high-grade leaks like Cerfolio Grade 4—are formidable complications following necrotizing pneumonia or infection. In patients with severe comorbidities, malnutrition, and uncontrolled diabetes who are deemed prohibitive risks for surgery and general anesthesia, traditional management options are drastically limited. This publication evaluates the feasibility and utility of flexible bronchoscopy-guided deployment of Amplatzer vascular plugs (AVPs) as a minimally invasive, lung-sparing alternative for BPF closure under local anesthesia.

👥 Study Design & Population

This publication is a Case Series evaluating two high-risk male patients:

Patient 1: A 61-year-old man with uncontrolled diabetes mellitus (HbA1c 13.2%), severe undernutrition (BMI < 18 kg/kg/m²), type 1 respiratory failure, and loculated pyopneumothorax secondary to right middle and lower lobe necrotizing pneumonia with a Cerfolio grade 4 BPF, failing 13 days of antibiotics and dual pigtail drainage.
Patient 2: A 51-year-old man with uncontrolled diabetes mellitus (HbA1c 9.2%), undernutrition, and right lower lobe necrotizing pneumonia complicated by a loculated pyopneumothorax and a Cerfolio grade 4 BPF, failing 8 days of drainage.

📈 Methodology & Rigor

As a clinical case report/series, the methodological rigor relies on the systematic documentation of the diagnostic workup and procedural execution:

Localization: Flexible bronchoscopy was successfully utilized to localize the exact site of the air leak to the right lower lobe (RLL) and its segmental/basal bronchi.
Intervention: Deployment of self-expanding nitinol mesh devices (Type 2 Amplatzer vascular plugs: 8 mm and 12 mm for Patient 1; 12 mm for Patient 2) was performed entirely under local anesthesia.
Follow-up: Rigorous longitudinal clinical and radiological follow-up was executed, including eventual device removal at 2 to 3 months and long-term evaluation at 6 months for recurrence.

🔬 Key Findings [or Planned Endpoints]

Procedural Success: Both procedures achieved immediate, complete resolution of the persistent air leak and prompt full lung re-expansion following AVP deployment.
Device Management: AVPs were successfully removed at 2 to 3 months post-deployment.
Long-term Outcomes: At 6 months of follow-up, both patients maintained sustained lung expansion without pneumothorax recurrence, and neither developed new pulmonary infections prior to or following plug removal.

⚖️ Critical Appraisal

Strengths: Demonstrates a clever, off-label application of vascular devices for airway closure in prohibitive surgical candidates. The technical advantage of AVPs—namely that they are retrievable and allow for controlled deployment—is a major benefit over traditional non-retrievable spigots or tissue glues.
Limitations: Being a small two-patient case series, the findings lack statistical power and broad generalizability. The success of this technique heavily depends on precise anatomical sizing, operator expertise in flexible bronchoscopy, and favorable bronchial anatomy. Furthermore, the long-term patency of the affected bronchi and functional recovery of the lung parenchyma post-removal require validation in larger cohorts.

💡 The Clinical Bottom Line

For the interventional pulmonology suite, Amplatzer vascular plugs offer a viable, lung-sparing, and retrievable bronchoscopic solution for managing high-grade bronchopleural fistulas in frail, surgically unfit patients under local anesthesia. Clinicians should keep AVPs in their procedural armamentarium as an advanced endobronchial closure tool when conventional conservative measures fail.

Extract Persistent air leak (PAL) and bronchopleural fistula (BPF) remain challenging to manage in patients with significant comorbidities or those unfit for surgery or general anesthesia. Limited evidence suggests that flexible bronchoscopy (FB) deployment of Amplatzer vascular plugs (AVPs) is a feasible, minimally invasive option for BPF closure.1-3 Patient 1 was a 61-year-old man with diabetes mellitus (DM; hemoglobin A1C, 13.2%) who developed necrotizing pneumonia of the right middle lobe and right lower lobe (RLL), complicated by type 1 respiratory failure, loculated pyopneumothorax, and Cerfolio grade 4 BPF despite antibiotics and dual pigtail drainage for 13 days (Figure 1A). Microbiological evaluation of pleural fluid and bronchoalveolar lavage grew Escherichia coli. Flexible bronchoscopy localized the leak to the RLL, and 2 type 2 AVPs (8 mm in the apical segment and 12 mm, occluding all basal segments; Figure 1B, C) were deployed under local anesthesia. The PAL resolved immediately with full lung expansion. Patient 2, a 51-year-old man with DM (hemoglobin A1C, 9.2%), RLL necrotizing pneumonia, type 1 respiratory failure, and loculated pyopneumothorax, developed BPF (Figure 1E). Microbiological evaluation revealed Pseudomonas aeruginosa in both sputum and pleural fluid. Despite 8 days of adequate drainage, a Cerfolio grade 4 air leak persisted. A 12-mm AVP was placed through FB in the RLL basal bronchi, resulting in complete resolution of PAL (Figure 1F, G, Video 1). Both patients were frail, were undernourished (body mass index < 18 kg/m2), and had uncontrolled DM, placing them at high risk for surgery (including postoperative complications) and general anesthesia, with other conventional BPF management options deemed unsuitable. Neither were new pulmonary infections identified before plug removal (2-3 months) nor pneumothorax recurrence at 6 months (Figure 1D, H). Amplatzer vascular plugs enable controlled, retrievable, lung-sparing bronchoscopic BPF closure under FB and local anesthesia, making it ideal for high-risk patients.4,5