DOI:10.2214/AJR.05.2217
AJR 2006; 187:W299-W301
© American Roentgen Ray Society
Bronchial Catheterization with a TIPS Dilator After Failure of Conventional Technique
Ji Hoon Shin1,
Ho-Young Song1,
Chang Jin Yoon2,
Jin Hyoung Kim1,
Jin-Oh Lim1,
Yong Jae Kim1 and
Heung-Kyu Ko1
1 Department of Radiology, Asan Medical Center, 388-1, Poongnap-dong, Songpa-gu,
Seoul, South Korea 138-736.
2 Department of Radiology, Seoul National University Hospital, Seoul,
Korea.
Received December 23, 2005;
accepted after revision February 28, 2006.
Address correspondence to J. H. Shin
(jhshin{at}amc.seoul.kr).
WEB
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Abstract
OBJECTIVE. A technique is presented for catheterization of an
obstructed bronchus when use of a conventional vascular catheter has failed.
In some cases, strictures become too stenotic or blunt for passage of a
guidewire, making further intervention impossible. We attempted to negotiate a
stricture opening using a transjugular intrahepatic portosystemic shunt (TIPS)
dilator with a guidewire inside it.
CONCLUSION. The catheterization technique with a TIPS dilator was
successful in nine cases in which use of conventional catheters and guidewires
had failed.
Keywords: airway • catheters • interventional radiology • TIPS
Introduction
Developments in the technology of catheter and guidewire systems have
allowed most cases of bronchial obstruction to be managed with balloon
dilatation or stent placement
[1,
2]. However, catheterization
and further intervention can be difficult when a bronchial stricture is tight
or complete [3,
4]. Although the conventional
technique with a guidewire and conventional vascular catheter under
fluoroscopic or bronchoscopic guidance usually is successful in
catheterization of an obstructed bronchus, in some cases catheterization is
not successful with these techniques. We describe successful catheterization
of an obstructed bronchus with a 9-French angled dilator inside a guidewire in
cases in which conventional catheterization failed.
Materials and Methods
Our institution does not require institutional review board approval for
retrospective studies. Between October 1994 and November 2005, a total of 247
bronchial balloon dilatation or stent placement sessions were undertaken in
137 patients. Six of the patients underwent nine sessions of bronchial balloon
dilatation (n = 7) or stent placement (n = 2) with a
transjugular intrahepatic portosystemic shunt (TIPS) dilator (Figs.
1A and
1B) and a guidewire after
failed catheterization of complete obstruction with conventional techniques
with a vascular catheter and guidewire. The patients were two men and four
women with an age range of 27-70 years (mean, 45.5 years). The underlying
diseases were tuberculous bronchial stricture in five patients and anastomotic
bronchial stricture after sleeve left lower lobectomy for bronchogenic
carcinoma in the sixth patient. The target obstructed bronchi were six left
main bronchi in four patients, two right main bronchi in one patient, and one
bronchus intermedius in one patient. Ipsilateral lungs were collapsed in five
patients with obstructed right or left main bronchi. There was no collapse of
the lung in the patient with obstructed bronchus intermedius. Exertional
dyspnea was present in all six patients.
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Fig. 1A —Devices (Flexor Check-Flo Introducer, Cook) used for
bronchial catheterization. Photograph shows 0.035-inch guidewire and 9-French
transjugular intrahepatic portosystemic shunt (TIPS) dilator.
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At our institution, bronchial balloon dilatation and stent placement are
done by interventional radiologists in collaboration with pulmonologists.
Pulmonologists perform flexible bronchoscopic evaluation and insert a
0.035-inch guidewire (Radiofocus Guide Wire M, Terumo) immediately before
bronchial intervention. All procedures are performed with the patient under
local anesthesia. In all study patients, attempts at negotiating the bronchial
opening with a 0.035-inch guidewire under bronchoscopic guidance failed.
Subsequent attempts at negotiating the opening with the same guidewire under
fluoroscopic guidance also failed. Although a Cobra catheter (Torcon NB
Advantage Catheter, Cook) or a 5-French sizing catheter (Royal Flush II, Cook)
was used to stabilize the guidewire and negotiate the tight opening of the
bronchi, the guidewire became twisted on itself, and the catheter repeatedly
moved backward against the opening (Figs.
2A,
2B,
2C, and
2D).
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Fig. 2B —40-year-old woman with tuberculous bronchial stricture. Chest
radiograph shows attempts at negotiating opening with Cobra catheter and
guidewire resulted in catheter moving backward and guidewire twisting on
itself.
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Fig. 2C —40-year-old woman with tuberculous bronchial stricture. Chest
radiograph shows transjugular intrahepatic portosystemic shunt dilator
(arrows) used to introduce guidewire into left main bronchus distal
to stricture.
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Interventional therapeutic options were considered, and the decision was
made to attempt to negotiate the opening with a TIPS dilator with a guidewire
inside it (Figs. 1A and
1B). It was reasoned that the
angle of the dilator would be similar to the angle between the trachea and the
bronchus and that the stiffness of the dilator would prevent backward curving
of the guidewire. The 9-French dilator comes with a 38.5-cm-long transjugular
intrahepatic sheath (Flexor Check-Flo introducer, Cook). The 9-French dilator
was introduced over the guidewire. After the tip of the dilator was positioned
on the opening of the bronchus, the guidewire was pushed to negotiate the
opening.
Results
Catheterization with a TIPS dilator and a 0.035-inch guidewire was
successful in all nine sessions. The mean time for traversing the strictures
was less than 2 minutes in all sessions. In three sessions, the distal portion
of the dilator was pushed into the bronchus beyond the stricture during
negotiation. In the other six sessions, only the guidewire was introduced into
the bronchus beyond the stricture. After removal of the sheath, introduction
of a centimeter sizing catheter was possible in all cases. Selective
bronchography with iopromide (Ultravist 300, Schering) showed very tight
strictures 0.5-4 cm (mean, 1.5 cm) long.
Subsequent interventional procedures, such as balloon dilatation and stent
placement, were successful in all patients. Atelectasis decreased or
disappeared in all patients. Exertional dyspnea also decreased or disappeared
in all patients. No complications, including bronchial perforation, related to
the procedure were encountered.
Discussion
In the tracheobronchial tree, balloon dilatation or temporary stent
placement can be an alternative to surgical procedures for benign stenosis,
and permanent stent placement can be used in the palliative management of
malignant stenosis. Despite the presence of a stenosis, airway interventions
such as balloon dilatation and stent placement require a residual lumen to
allow passage through the stricture with a guidewire. Gilchrist et al.
[5] described the use of
vascular catheters and hydrophilic guidewires for traversing severe airway
strictures that were impassable with traditional wire technology. In some
circumstances, strictures become too stenotic or blunted for passage of a
guidewire or even liquid contrast medium, essentially obliterating the lumen
and making further intervention impossible
[3,
4]. Furthermore, when
atelectasis is present, the trachea deviates toward the collapsed lung, making
negotiation of the opening more difficult because the angle between the
trachea and ipsilateral bronchus becomes more acute.
In the present study, patients had undergone multiple attempts at traversal
of obstruction of the bronchus with so-called traditional wire and vascular
techniques, and all such attempts were unsuccessful. We found that use of a
TIPS dilator allowed introduction of the guidewire into the stricture without
difficulty. In addition to its suitable angle for passage into the bronchus, a
TIPS dilator has a tapered distal end. The technique can be performed easily
with additional preparation of a TIPS dilator and can be used for obstruction
of the main bronchus and of the bronchus intermedius. We believe practitioners
do not need previous training in this method and can use the technique
immediately as they see fit because it is very simple and safe.
Use of a dilator in recanalization of an occluded esophagus after repair of
esophageal atresia was described in a report by Vo et al.
[6]. Those authors used a Chiba
needle inside a 6-French dilator. The dilator appeared to function as a sheath
stabilizing the Chiba needle. A vascular sheath or homemade sheath also has
been used to stabilize guidewires and catheters. For bronchial intervention,
Raza et al. [7] described a
percutaneous transtracheal approach to stent placement. They deployed
bronchial stents by introducing 7- to 12-French vascular sheaths by the
percutaneous route. In gastroduodenal and colonic interventions, vascular and
homemade sheaths have been used to overcome tortuous routes and to facilitate
passage of guidewires and catheters
[8,
9]. In our case, we believe the
TIPS dilator also functioned as a sheath for stabilizing the guidewire. This
technique avoided the risks associated with the percutaneous approach. In
addition, the curvature of the distal portion of the dilator helped direct the
guidewire into the opening.
A risk of catheterization with a TIPS dilator is bronchial perforation,
which can result in pneumomediastinum and pneumothorax. However, we believe
this complication is unlikely to occur because the soft end of the guidewire
is introduced into the stricture, and the stricture area, which has a
thickened bronchial wall, is not easily perforated.
Although this study involved only a small number of patients, the
catheterization technique with a TIPS dilator appears to be useful in cases of
failed catheterization of bronchial obstruction with conventional catheters
and guidewires.
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Abstract
Introduction
