Presentation
Bilateral sequential single lung transplant (BSSLTx) for severe post infectious bronchiectasis
Patient Data
Age: 55
Gender: Male
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- bilateral cystic bronchiectasis particularly the middle lobe
- air-fluid levels in the cystic spaces due to chronic infection
- architectural distortion and pleuroparenchymal scarring secondary to fibrosis
- volume loss in the right hemithorax
- main pulmonary artery is enlarged
- heart size is enlarged
Post biLat lung transplant CXR
From the case:
Anastomotic dehiscence ("stump leak") post lung transplant
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- status post bilateral lung transplant (BSSLTx) with bilateral hilar surgical clips
- tracheostomy in situ
- nasogastric tube (NGT) in situ
- right dual lumen (Vascath) central venous line (CVL) appropriately positioned with its tip at the cavoatrial junction
- left PICC line appropriately positioned with its tip at the cavoatrial junction
- three chest tubes in situ
- moderate right pleural effusion
- no pneumothorax
- surgical staples in the right chest wall
Anastomotic dehiscence post...
From the case:
Anastomotic dehiscence ("stump leak") post lung transplant
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Anastomotic dehiscence post transplant CXR
- new right hemopneumothorax is most concerning for airway dehiscence
- pneumothorax suggests airway dehiscence and stump-plerual fistula
- vascular compromise can be confirmed on contrast enhanced CT
- the term "stump" dehiscence is often used but can cause confusion as it doesn't discriminate between pulmonary arterial, bronchial arterial, or airways dehiscence
- new left pneumothorax
- tubes and lines appropriately positioned (see above)
- tracheostomy
- NGT
- right Vascath
- left PICC line
- chest tubes
Post subsequent Rt pn...
From the case:
Anastomotic dehiscence ("stump leak") post lung transplant
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Post subsequent Rt pneumonectomy CXR
- subsequent right pneumonectomy for infarcted right lung post vascular and airways dehiscence (note the additional clips at the right stump to secure the pulmonary vessels and right main bronchus)
- high density material at the right stump and adjacent to the right intercostal catheter (ICC) represents "stump glue" adhesive to further secure the right stump
- large right hemopneumothorax (note the crisp outline of the right atrium)
- post surgical left lower lobe atelectasis and pleural effusion
- tubes and lines appropriately positioned
- tracheostomy
- right Vascath
- left PICC line removed
- NGT replaced with a nasojejunal tube (NJT)
Case Discussion
This case highlights the devastating consequences of "stump" dehiscence following lung transplantation.
The presence of a new or persistent pneumothorax following a transplant should raise the suspicion of airways dehiscence. First line treatment is directed at sealing the resultant bronchopleural fistula with with endobronchial, VATS, or open adhesive ("stump glue") or clipping.
A contrast CT is typically performed to exclude associated pulmonary arterial or bronchial arterial vascular compromise. Resultant pulmonary infarction may necessitate a pneumonectomy (as in this case) and carries a poor prognosis.