1646 AJR:175, December 2000 ronchopleural fistulas may occur as a result of the following: rup- ture of a lung abscess, bulla, or cyst; direct barotrauma; breakdown of a su- ture line after pulmonary resection; erosion caused by either a chronic inflammatory pro- cess or an invasion by a malignancy; and physical trauma, which may be accidental or iatrogenic, such as lung biopsy or chest tube insertion. Bronchopleural fistulas may also occur spontaneously. Fistulas can be man- aged initially with tube thoracostomy and suction, but except for a few that heal with this treatment, operative intervention has been the mainstay of management for most fistulas. Various successful nonsurgical tech- niques with bronchoscopes have also been described. We describe endobronchial closure of a chronic bronchopleural cutaneous fistula with glue and metallic coils delivered through angiography catheters under fluoroscopic guidance; this procedure was performed with the patient under topical anesthesia. Subject and Methods A 28-year-old man with cryptogenic hepatic cir- rhosis and multiple pyogenic liver abscesses pre- sented with right thoracic empyema. Chest tube drainage of the empyema was performed for 10 days. Two weeks after the removal of the chest tube, the patient returned with fever, cough, and leakage of air from the chest tube insertion site when coughing and during forced expiration, sug- gestive of a bronchopleural cutaneous fistula. Chest radiographs revealed a large loculated pyopneu- mothorax with loculations posteromedially and an- terolaterally (Fig. 1A). A 12-French Malecot catheter with water-seal drainage was placed in the posterior dependent loculation under sonographic and fluoroscopic guidance, and IV antibiotics were administered. Continuous drainage of pus with leakage of air was observed under water seal. Cavitogram ob- tained via this catheter revealed a large, irregular, loculated empyema cavity. After 10 days complete resolution of the empyema was seen with a result- ant bronchopleural cutaneous fistula. Bronchogra- phy was planned to localize the fistula site and embolize the fistula. After the tracheobronchial tree was topically anesthetized with 5 mL of lidocaine (Xylocaine 2% spray; Astra-Idl, Bangalore, India) adminis- tered through a 9-French minitracheotomy chan- nel, a 6-French multipurpose angiography catheter placed over a 0.035-inch hydrophilic guidewire (Terumo, Tokyo, Japan) was used. With limited bronchography and small amounts of nonionic contrast medium, a fistulous tract from one of the subsegmental bronchi of the middle lobe to the loculated pneumothorax cavity was localized (Fig. 1B). With a coaxial microcatheter system (Tracker- 18; Target Therapeutics, Fremont, CA), the fistula was embolized with 0.5 mL of N-butyl-2-cy- anoacrylate (Nectacryl; Dr. Reddy’s Laboratories, Hyderabad, India) mixed with 1.0 mL of iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France). Immediately after embolization, the pneumothorax cavity collapsed. However, 4 hr after the procedure the patient again started having air drainage through the chest tube, and repeated chest radio- graphs showed reappearance of the pneumothorax. A second procedure to embolize the fistulous tract and the involved bronchus as peripherally as possible was performed. Using a 6-French multi- purpose catheter, we placed two approximately 2 × 10 mm metallic coils in the fistulous tract. Once the coils were in place, 1.0 mL of N-butyl-2-cy- anoacrylate admixed with 2.0 mL of iodized oil (Lipiodol) was injected through a microcatheter; the fistula and the involved subsegmental bronchus were occluded (Fig. 1C). The patient had prompt reduction in the size of the loculated pleural cavity (Fig. 1D), and neither air nor pus discharge was observed through the chest tube over the next few days. The tube was removed after 1 week. Over 6 months of follow-up, the patient had no com- plaints pertaining to his chest. Sonograms and chest radiographs showed complete resolution of the empyema with healing of the fistula. Discussion Bronchopleural fistulas, particularly those oc- curring after empyema, are rather difficult to treat. Operative intervention is usually required if tube thoracostomy and suction fail. Various surgical procedures such as direct repair, thora- coplasty, myoplasty, omental transposition, and Endobronchial Closure of a Bronchopleural Cutaneous Fistula Using Angiography Catheters Rajan Jain 1 , S. S. Baijal 1 , R. V. Phadke 1 , C. K. Pandey 2 , V. A. Saraswat 3 Received February 23, 2000; accepted after revision May 31, 2000. 1 Department of Radio-diagnosis, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Rae-Barelli Rd., Lucknow 226014, India. Address correspondence to S. S. Baijal. 2 Department of Anesthesiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow 226014, India. 3 Department of Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow 226014, India. AJR 2000;175:1646–1648 0361–803X/00/1756–1646 © American Roentgen Ray Society Technical Innovation B Downloaded from www.ajronline.org by 52.73.204.196 on 05/16/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved