Airway abnormality, Intervention, Cutting balloon catheter

8 years/Female

Even after antituberculous medication for 9 months, follow‐up chest radiography showed total collapse of the right lung one year previously. Stenosis of the right main bronchus and bronchus intermedius was treated with conventional balloon(8mm‐6cm) dilatation, but near obstruction of the right main bronchus was shown on three‐month follow‐up imaging studies.

Recurrent bronchial stenosis at right main bronchus & bronchus intermedius due to endobronchial tuberculosis.

Initial chest CT shows that high grade stenosis(arrows) at the right main bronchus and atelectasis of right upper lobe. Cutting balloon dilation (8‐mm diameter) was performed, followed by conventional balloon dilation (10‐mm diameter). Radiographs taken during cutting balloon dilation showed waist formation, indicating area of stricture. On 2‐ and 6‐month follow‐up chest CT scans showed that stenosis was markedly improved.

The pharynx and larynx were topically anesthetized with an aerosol spray. Sedation was performed with midazolam by bronchoscopists under the monitoring of oxygen saturation and electrocardiography. A 0.035‐inch angled exchange guide wire (Terumo, Tokyo, Japan) was inserted through the bronchoscopic channel and positioned across the stenosis. After removal of the bronchoscope, using fluoroscopic guidance, a straight 5‐Fr graduated catheter (Cook, Bloomington, IN, USA) was passed over the guide wire to the distal part of the obstruction, and contrast medium (Iopromide [Ultravist 300]; Schering, Berlin, Germany) was injected through the catheter to opacify the obstruction so that the degree and length of it could be measured. A guide wire exchange was performed, and a 0.014‐inch guide wire (Boston Scientific/Medi‐tech) was placed. 8‐mm‐diameter, 2‐cm‐length cutting balloon catheter (Boston Scientific/Medi‐tech) with four blades (microtomes) was then placed over the guide wire and across the stenosis, and inflated with diluted contrast medium at inflation pressures as high as 10 atm (as established by a pressure‐gauge monitor). The working height of microtomes was approximately 0.127mm. The cutting balloon catheter was fully dilated for 30 seconds. Balloon exchange was performed, and second conventional balloon dilation with 10‐mm‐diameter, 4‐cm‐length balloon catheter, which was fully dilated for one minute.

High‐pressure balloon dilation has become an accepted treatment for benign tracheobronchial strictures. However, they are sometimes fibrotic and tight in nature, so low primary and secondary patency rates, 24% and 20%, respectively, have been reported in high‐pressure balloon dilation. Temporary stent placement is safe and effective in selected patients with benign tracheobronchial strictures, however stent placement accompanies problems of tissue hyperplasia, stent migration, and sometimes makes surgery impossible. Cutting balloons have been used to dilate rigid strictures in the blood vessels, ureter, biliary system, and esophagus, report of their use in the treatment of benign bronchial strictures is limited. The cutting balloon features three or four microtomes fixed longitudinally on the surface of a noncompliant balloon. The microtomes make controlled longitudinal incisions in the inner wall of the lumen, making predictable crack propagation in an orderly fashion. As the cutting balloon has successfully created controlled intimal disruption in blood vessels and controlled mucosal incision in various strictures of the ureter, biliary system, and esophagus, successful musocal incision was possible in tight mucosa of the bronchial strictures in the present cases. The tight stricture was gradually dilated without resistance with cutting balloon dilation and subsequent conventional balloon catheter was also fully dilated with little resistance. As opposed to the arteries in which cutting balloon dilation carries a risk of perforation, there has been no major complications such as lumen rupture in cases of cutting balloon dilation for nonvascular luminal strictures; no extraluminal contrast material was found. Only blood staining on the balloon surface or hemobilia without requirement of blood transfusion was reported in the biliary system and esophagus. We think that the walls of the stenotic non‐vascular luminal organs were thick enough not to be ruptured with a currently using balloon catheter. However, wall thickness would be different according to the kind of organ and severity of the stricture, so, careful selection of the diameter of the cutting balloon and judicious gradual inflation are important

1. Kim JH, Shin JH, Song HY, Shim TS, Yoon CJ, Ko GY. Benign tracheobronchial strictures: long‐term results and factors affecting airway patency after temporary stent placement. AJR Am J Roentgenol 2007;188:1033‐1038 2. Cejna M. Cutting balloon: review on principles and background of use in peripheral arteries. Cardiovasc Intervent Radiol 2005;28:400‐408 3. Atar E, Bachar GN, Bartal G, et al. Use of peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures. J Vasc Interv Radiol 2005;16:241‐245 4. Wilkinson AG, MacKinlay GA. Use of a cutting balloon in the dilatation of caustic oesophageal stricture. Pediatr Radiol 2004;34:414‐416

Fig. 1 8-year-old girl with marked right bronchial stricture due to endobronchial tuberculosis. A, Reconstructed CT image shows high grade stenosis (arrows) at the right main bronchus and atelectasis of right upper lobe.

B & C Radiographs taken during 8－mm cutting balloon dilation show waist formation, indicating area of stricture. The stricture was fully dilated (C)

B & C Radiographs taken during 8－mm cutting balloon dilation show waist formation, indicating area of stricture. The stricture was fully dilated (C)

D, Radiograph of conventional balloon dilation with 10mm－diameter high pressure balloon catheter.

E & F Reconstructed CT images obtained two (E) and six (F) months after cutting balloon dilation show that the stricture is markedly improved.

E & F Reconstructed CT images obtained two (E) and six (F) months after cutting balloon dilation show that the stricture is markedly improved.