Lung transplant anastomotic airway complications and bronchoscopic management

Abstract

Airway complications after lung transplantation have significantly reduced in incidence over the past several decades, yet remain a persistent source of morbidity and mortality in this patient population.Complications are most commonly seen at the surgical anastomosis and include regional ischemic necrosis, dehiscence, hypertrophic granulation tissue, fistula, tracheobronchomalacia and bronchial stenosis. The mechanism for developing airway complications is incompletely understood, but may be related to airway ischemia, inflammation or infection that contribute to poor anastomotic and wound healing. Risk factors have been linked to donor and recipient characteristics, perioperative conditions, and immunosuppressive regimens. Flexible bronchoscopy remains the gold standard modality for diagnosis, with airway complications arising in the early and late posttransplant period. The management approach is multifaceted and individualized for each airway complication. Bronchoscopic techniques include balloon or rigid dilation, ablative modalities such as cryotherapy and electrocautery, and in advanced cases, airway stenting. Like other benign airway pathologies, silicone stents are generally preferred to self-expanding metallic stents. Surgery is usually reserved for cases that fail to improve with more conservative measures. Herein, we provide a comprehensive review of the risk factors, clinical manifestations, diagnostic classifications, and management strategies of lung transplant airway complications.