Tracheobronchial tree, stenosis or obstruction Interventional procedures, complications Balloon dilation

31-year-old woman

Balloon dilation was performed in a 31-year-old woman for tuberculous tracheobronchial stenosis because of her recent symptoms such as aggravated cough, dyspnea, and 3 kg weight loss for seven months. Pre-balloon pulmonary function test (PFT) showed a forced expiratory volume in one second (FEV1) of 1.3 (45%, predicted) and a forced vital capacity (FVC) of 2.0 (54%, predicted). Immediately after balloon dilation, she complained of mild chest pain and expectorated some blood-tinged sputum. On bronchoscopy (not shown) obtained immediately after balloon dilation, tracheal laceration at the posterior tracheal wall was observed. The length and depth were estimated as about 5 cm and 8 mm on bronchoscopy. Her vital sign was stable without fever or chills, and there was no change of hemoglobin level. Her chest pain and blood-tinged sputum disappeared within 24 hours. Therefore, she was prescribed only antibiotics to prevent possible infection and was discharged from hospital five days later. Eight months after balloon dilation, her symptoms were much improved. Follow-up PFT eight months after balloon dilation showed a FEV1 of 1.8 (63%, predicted) and a FVC of 3.3 (89%, predicted); FEVland FVC increased as much as 18% and 45%, respectively, compared with those of the predilation PFT. She has maintained her symptomatic improvement without recurrence for ten months.

Deep tracheal laceration with pneumomediastinum after balloon dilation

Four days before balloon dilation, chest CT including 3-dimensional (3D) reconstructions showed a 6-cm-long tracheal stenosis and a 1.5-cm-long right main bronchial stenosis, combined with tracheal and right main bronchial wall thickening (Fig 1). The diameters of the narrowed segment in the trachea and right main bronchus was 6 mm and 2 mm, respectively, while that of the normal segment in the trachea and right main bronchus was 16 mm and 11 mm, respectively. CT immediately after balloon dilation revealed deep longitudinal laceration at the posterior tracheal wall and pneumomediastinum (Fig 3). Follow -up CT scans (Fig 4) obtained eight months following balloon dilation, the deep laceration completely healed and the widened tracheal lumen was maintained.

A. Anteroposterior view of three-dimensional (3D) reconstruction CT shows a 6-cm-long tracheal stenosis from mid-trachea to carina and a 1.5-cm-long right main bronchial stenosis. B. Axial CT scan at the level of mid trachea shows tracheal stenosis (arrow) with wall thickening (arrowheads).

A. Initially, right main bronchial stenosis (arrowheads) is fully dilated with a 4-cm-long and 10-mm-diameter balloon. B. Tracheal stenosis (arrowheads) is then fully dilated with a 12-cm-long and 18-mm-diameter balloon.

A. 3-D reconstruction image. B. Pneumomediastinum C. Virtual bronchoscopy image.

A. Anteroposterior view of 3D reconstruction CT shows improved right main bronchial (arrows) and tracheal stenosis (arrowheads). B. Lateral view of 3D reconstruction CT demonstrates disappeared deep laceration at the posterior tracheal wall (arrowheads). C. Axial CT scan at the level of mid trachea shows the improvement of the stenosis (arrow) and wall thickening (arrowheads) in the involved trachea.

Topical anesthesia of the oropharynx was achieved prior to the procedure with an aerosol spray of lidocaine hydrochloride (Dai Han, Seoul, Korea). With bronchoscopic guidance, a 0.035-inch exchange guide wire (Terumo, Tokyo, Japan) was inserted across the stenoses in the trachea and right main bronchus into the distal portion of them through the working channel of the bronchoscope. After withdrawing the bronchoscope while the guide wire was in place, a straight 5-F graduated sizing catheter (Cook Bloomington, IN) was passed over the guide wire to the distal portion of the stenoses in order to measure their length. Using fluoroscopic guidance, the location of the narrowed tracheal and bronchial lumen were marked on the patient's skin with radiopaque markers. After measuring the length of the stenoses, we initially dilated the right main bronchial stenosis, and subsequently the tracheal stenosis. A 6-mm-diameter balloon catheter was used first in a severe right main bronchial stenosis to provide for passage of the larger balloon catheter. Then, the balloon (Boston Scientific/Medi-tech, Watertown, Mass; 10 mm in diameter and 4 cm long for bronchial stenosis, 18 mm in diameter and 10 cm long for tracheal stenosis) was slowly inflated manually with a diluted water-soluble contrast medium. One session of balloon inflation was performed for the right main bronchial stenosis with balloon inflation time of two minutes. While, four sessions of balloon inflation were performed at a time for the tracheal stenosis with each balloon inflaton time of 30 seconds, therefore, the total inflation time was two minutes. There was waist formation of the inflated balloon catheter at the stricture segment, however, the waist became diaappeared soon without much resistance (Fig 2).

Previous reports have stated that afibrotic process may be more amenable to successful balloon dilation than other processes such as inflammation or calcification (3,6). Although the predominant fibrotic process can be easily dilated and can suggest good clinical outcome, there may be potential complication such as laceration or even free perforation after sudden balloon dilation of fibrotic stenosis because of its hardness or stiffness. In this patient in our report, the history of tuberculosis was more than ten years and the predominant fibrotic proc- ess was confirmed on bronchoscopy. Previously, clinical outcome and follow -up data of deep tracheal or bronchial laceration has not been documented in detail. In our case, interestingly, the long and deep tracheal laceration as well as pneumomediastinum disappeared completely during the follow-up of ten months after balloon dilation. Lee et al (7) also stated briefly that two deep lacerations with pneumomediastinum left no subsequent clinical sequelae without any further description. We assumed that even though deep laceration occurs after dilation of fibrotic stenosis, good clinical outcome, in some cases, can be achieved because the lumen of stenotic segment may be widened enough after the tear of fibrotic tissue, thereby rendering deep laceration, and deep laceration may heal soon with growth of granulation tissue. Balloon dilation for congenital tracheal stenosis is another illustration of the same point; rupture of the complete cartilaginous rings by balloon dilation represents a prerequisite step for increase in the luminal diameter itself (13). In our case, bronchoscopy immediately after balloon dilation was very useful for early detection of the deep tracheal laceration and CT including 3D reconstructions was very helpful to delineate the extent of the deep laceration as well as pneumomediastinum.

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