Pathological findings after right lung transplantation in a patient with fibrosing alveolitis

Abstract

and the Institute of Diseases of the Chest, Brompton Hospital, London SYNOPSIS The pathological findings in a patient who died two months after right lung transplantation for fibrosing alveolitis are reported. The cause of death was haemoptysis, due to penetrating ulceration causing a fistula between the surface of the cartilagenous part of the main bronchus of the donor lung and the right upper lobe pulmonary artery. The opening in the donor bronchus was immediately distal to the line of the bronchial anastomosis and through an actively inflamed area. Other parts of the donor bronchus had microscopic changes suggesting ischaemia, emphasizing that inadequacy of blood supply to the donor extrapulmonary bronchus is one of the most serious hazards of lung transplantation. Within the lung, histological features of rejection were mild and there was minimal evidence of infection. Another question raised by this case is whether the donor lung was in the process of developing the original disease, evidence for which was sought electron microscopically but was not proven.

Bronchovascular Fistula Formation: A Rare Airway Complication After Lung Transplantation

“…[7][8][9][10][11][12][13][14] Unifying factors in these cases are mechanical stress of the vascular system (ie, aneurysm or surgical intervention) and/or local infection, with the most common fistula site occurring between the aorta Table 2). Anastomotic complications after lung transplantation, including bronchial stenosis, bronchomalacia, infection, and dehiscence, are not uncommon, with an estimated frequency of 5% to 18% and an associated 2% to 3% mortality rate.…”

“…7,12,14 Chest X-ray is usually non-specific but may show mediastinal widening and lung parenchyma opacity due to hemorrhage. CTA and MRI/MRA rarely reveal the fistulous tract because of the clot, but may provide suggestive clues such as vascular or airway anatomy abnormalities, lung parenchyma opacities or consolidation, or airway compression.…”

“…7,14 Bronchoscopy can be very useful by possibly identifying the fistula and also by ruling out other possible sources of hemoptysis, but carries the risk of bleeding if a clot is dislodged and as such should be done cautiously. 7,12,14 Other, more invasive techniques, if a bronchovascular fistula is highly suspected, include aortography, intravascular ultrasound, and transesophageal echocardiogram. 7,12 In those patients in whom a fistula is diagnosed, successful treatment has been reported.…”

“…7,12,14 Other, more invasive techniques, if a bronchovascular fistula is highly suspected, include aortography, intravascular ultrasound, and transesophageal echocardiogram. 7,12 In those patients in whom a fistula is diagnosed, successful treatment has been reported. Surgical repair has been the traditional treatment option, but has a high morbidity and mortality, which can be 20% to 24%.…”

“…Surgical repair has been the traditional treatment option, but has a high morbidity and mortality, which can be 20% to 24%. 7,12 In one extreme case, pneumonectomy was required. 22 In more recent years, the less invasive option of endovascular repair with stent graft placement has been reported.…”