DOI:10.2214/AJR.07.2413
AJR 2008; 190:W130-W132
© American Roentgen Ray Society
Cutting Balloon Treatment for Recurrent Benign Bronchial Strictures
Ji Hoon Shin1,
Ho-Young Song1,
Jin Hyoung Kim1,
Kyung-Rae Kim1,
Jeong-Hoon Park1,
Tae Sun Shim2 and
Yeon-Mok Oh2
1 Department of Radiology and Research Institute of Radiology, University of
Ulsan College of Medicine, Asan Medical Center, 388-1, Pungnap-dong,
Songpa-gu, Seoul 138-736, Korea.
2 Department of Internal Medicine, University of Ulsan College of Medicine, Asan
Medical Center, Seoul, Korea.
Received April 15, 2007;
accepted after revision September 4, 2007.
Address correspondence to H. Y. Song
(hysong{at}amc.seoul.kr).
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Abstract
OBJECTIVE. Benign airway strictures refractory to balloon dilatation
or stent placement remain a challenge in interventional radiology. This
article describes the successful use of a cutting balloon to treat three cases
of recurrent tuberculous bronchial strictures.
CONCLUSION. In three patients, cutting balloon dilatation was found
to be safe and effective and did not cause complications. Although the dilated
lumen showed partial reduction over the 6- to 12-month follow-up, subjective
functional symptoms and dyspnea grade improved.
Keywords: airway • bronchial strictures • chest imaging • interventional technique • tracheobronchial strictures • tuberculosis
Introduction
High-pressure balloon dilatation has become an accepted treatment for
benign tracheobronchial strictures
[1]. However, such strictures
can be fibrotic and tight, which has resulted in reports of low primary and
secondary patency rates (24% and 20%, respectively) after high-pressure
balloon dilatation [1].
Although temporary stent placement is safe and effective in selected patients,
stent placement in benign tracheobronchial strictures can be associated with
problems, such as tissue hyperplasia and stent migration, and can make surgery
impossible [2].
Cutting balloons have been used to dilate rigid strictures in blood
vessels, the ureter, the biliary system, and the esophagus
[3–8].
However, few reports detail the use of cutting balloons to treat benign
bronchial strictures.
Subjects and Methods
The first patient was an 8-year-old girl diagnosed 2 years earlier with a
right bronchial stricture due to endobronchial tuberculosis. Despite taking
antituberculous medication for 9 months, a total collapse of the right lung
occurred 1 year after diagnosis. She underwent conventional balloon dilatation
with an 8-mm-diameter balloon catheter (XXL, Boston Scientific/Medi-tech) in
the right main bronchus and bronchus intermedius 3 months earlier. A 3-month
follow-up chest 3D CT examination showed near total obstruction of the right
main bronchus (Fig. 1A,
1B,
1C,
1D,
1E,
1F,
1G). Cutting balloon dilatation
was recommended because the stricture appeared to be resistant to conventional
balloon dilatation.
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Fig. 1A —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Reconstructed CT image shows high-grade stenosis
(arrow) at right main bronchus and atelectasis of right upper
lobe.
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Fig. 1B —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Radiographs obtained during 8-mm cutting balloon
dilatation show waist formation (arrow, B), indicating
stricture area, and fully dilated stricture (C).
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Fig. 1C —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Radiographs obtained during 8-mm cutting balloon
dilatation show waist formation (arrow, B), indicating
stricture area, and fully dilated stricture (C).
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Fig. 1D —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Radiograph obtained during conventional balloon
dilatation shows 10-mm-diameter high-pressure balloon catheter.
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Fig. 1E —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Reconstructed CT images obtained at 2 (E),
6 (F), and 12 (G) months after procedure show marked stricture
improvement (arrows).
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Fig. 1F —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Reconstructed CT images obtained at 2 (E),
6 (F), and 12 (G) months after procedure show marked stricture
improvement (arrows).
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Fig. 1G —8-year-old girl with marked right bronchial stricture due to
endobronchial tuberculosis. Reconstructed CT images obtained at 2 (E),
6 (F), and 12 (G) months after procedure show marked stricture
improvement (arrows).
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The second patient was a 32-year-old woman diagnosed when she was 16 years
old with a left bronchial stricture due to endobronchial tuberculosis.
Antituberculous medication was administered for 4 months at the time of
diagnosis. She underwent two sessions of conventional 10-mm-diameter balloon
dilatation when she was 20 and 24 years old. Thereafter, she occasionally
experienced dyspnea. At the time of the current presentation, she was
experiencing fever, coughing, sputum production, and dyspnea. Airway
evaluation using chest 3D CT showed that the left main bronchus had severely
narrowed to approximately 2 mm in diameter (80% luminal narrowing). Cutting
balloon dilatation was recommended because the stricture appeared to be very
tight.
The third patient was a 60-year-old woman diagnosed when she was 26 years
old with a right bronchial stricture due to endobronchial tuberculosis.
Antituberculous medication was administered several times until she was 50
years old. She underwent conventional balloon dilatation with a 12-mm-diameter
balloon catheter (XXL) in the right main bronchus 9 years earlier. Thereafter,
she occasionally experienced dyspnea. At the time of the current presentation,
she was experiencing coughing, sputum production, and dyspnea that had started
1 month earlier. Airway evaluation using chest 3D CT showed the right main
bronchus had narrowed to approximately 4 mm in diameter (43% luminal
narrowing). Cutting balloon dilatation was recommended because the stricture
appeared to be resistant to conventional balloon dilatation.
All procedures and associated chart reviews were performed with the
approval of our university's institutional review board. The experimental
nature of this proposed treatment was fully explained to the patient or
patient's parent. The pharynx and larynx were topically anesthetized using an
aerosol spray. Bronchoscopists established sedation of the patient using
midazolam while monitoring oxygen saturation and ECG. A 0.035-inch angled
exchange guidewire (Radiofocus Guide Wire M, Terumo) was inserted through the
bronchoscopic channel and positioned across the stenosis. The bronchoscope was
removed, and then using fluoroscopic guidance, a straight 5-French graduated
catheter (Royal Flush II angiographic catheter, Cook) was passed over the
guidewire to the distal region of the obstruction, and an opaque contrast
medium (iopromide [Ultravist 300, Bayer HealthCare]) was injected through the
catheter to allow measurement of the degree and length of the obstruction. A
guidewire exchange resulted in a 0.018-inch guidewire (Radiofocus Guide Wire
M) being positioned. An 8-mm-diameter, 2-cm-length cutting balloon catheter
(Peripheral Cutting Balloon, Boston Scientific/Medi-tech) with four blades
(microtomes) was then placed over the guidewire and across the stenosis and
was inflated with diluted contrast medium at pressures as high as 10 atm (as
established by a pressure-gauge monitor). The working height of the microtomes
was approximately 0.127 mm. For all three patients, the cutting balloon
catheter was fully dilated for 30 seconds. The balloon was then exchanged for
a 10-mm-diameter, 4-cm-length balloon catheter to perform a conventional
balloon dilatation, which was fully dilated for 1 minute in three
patients.
After balloon dilatation, bronchoscopy was performed to evaluate stricture
changes and to investigate any complications.
Results
Fluoroscopic images at the commencement of balloon inflation clearly showed
the waist of the stenosis on the wall of the cutting balloon. An increase in
balloon inflation pressure resulted in the waist gradually and completely
disappearing. Bronchography performed after dilatation revealed marked
improvement in the appearance of the stenosis in all patients (Fig.
1A,
1B,
1C,
1D,
1E,
1F,
1G). For the first patient, the
stenosis diameter increased from 0 to 5.2 mm. For the second patient, the
stenosis diameter increased from 2 to 7.1 mm. For the third patient, the
stenosis diameter increased from 4 to 7.8 mm. The patients tolerated the
procedure well, and there was only a minimal amount of blood staining on the
balloon surfaces. Passage of the bronchoscope was possible after the
procedure. There were no procedure-related complications.
The patients described a subjective improvement in respiration and greater
ease in clearing secretions after the procedure. Dyspnea evaluated with the
Hugh-Jones classification [9]
showed improvement of more than one grade in all patients—that is, from
grade III to I in all patients after balloon dilatation.
In the first patient, follow-up 3D chest CT scans at 2, 6, and 12 months
after the procedure showed stenosis diameters of 4.4, 4.4, and 4.3 mm,
respectively (17.3% stenosis) (Fig.
1A,
1B,
1C,
1D,
1E,
1F,
1G). In the second patient,
follow-up chest 3D CT scans at 6 and 12 months after the procedure showed a
stenosis diameter of 4.4 and 4.2 mm (40.8% stenosis), respectively. In the
third patient, follow-up chest CT scans 6 months after the procedure showed a
stenosis diameter of 7 mm (10.3% stenosis).
Discussion
Resistant stenotic benign airway lesions remain a challenge for physicians
and interventional radiologists. Benign airway strictures are the sequelae of
endobronchial tuberculosis or postoperative anastomotic adhesions and lead to
a reduced functional airway diameter and eventually to atelectasis.
The cutting balloon features three or four microtomes fixed longitudinally
on the surface of a noncompliant balloon. The microtomes create controlled
longitudinal incisions in the inner wall of the lumen, making predictable
crack propagation in an orderly fashion
[3]. Cutting balloons have been
successfully used to create controlled intimal disruption in blood vessels and
controlled mucosal incisions in various strictures of the ureter, biliary
system, and esophagus. The present work found that cutting balloons were also
successful in creating mucosal incisions in the tight mucosa of bronchial
strictures. The tight stricture was gradually dilated without resistance using
a cutting balloon, and the subsequent conventional balloon catheter was also
fully dilated with little resistance. In cases of ureteral and biliary system
stenoses, the procedural success rate was more than 80–90%; however, the
reported follow-up period was less than 10 months
[4,
8].
The protocol described in this article involved initial dilatation with an
8-mm cutting balloon followed by dilatation with a 10-mm conventional balloon,
as described previously for biliary system and esophageal strictures
[4,
5]. We believe that performing
dilatation with the larger-diameter conventional balloon was reasonable
because the normal diameter of the bronchus is approximately 10 mm. We
anticipated that conventional balloon dilatation using a larger-diameter
balloon than the cutting balloon would dilate the stricture to the desired
diameter. We believe that this gradual shift to the larger dilatation diameter
may contribute to the effectiveness and safety of this procedure. Although the
diameter of the widened lumen became smaller during the 6- to 12-month
follow-up period, subjective functional improvement was maintained and dyspnea
grade also improved.
Cutting balloon dilatation in arteries can lead to perforation
[10]. To date, however, no
major complications such as lumen rupture have been reported for cutting
balloon dilatation of nonvascular luminal strictures; no extraluminal contrast
material has been observed [4,
5,
7,
8]. The only reported
complications have been blood staining on the balloon surface or hemobilia,
which did not require a blood transfusion when cutting balloon dilatation was
used in the biliary system and the esophagus
[4,
5]. We believe that the walls
of the stenotic nonvascular luminal vessels are thick enough to prevent
rupture by the balloon catheter that we used. However, wall thickness may
differ according to the organ and the severity of the stricture. Therefore,
the cutting balloon diameter should be carefully considered, and inflation
should be gradual.
In summary, cutting balloon dilatation may be a safe and effective
treatment for recurrent benign bronchial strictures. However, routine
application of this procedure awaits further evaluation in a large series of
patients.
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Abstract
Introduction
