Percutaneous vascular plug in management of an acquired broncho pleural cutaneous fistula

Bronchopleural fistula (BPF) / broncho pleural cutaneous fistula is an abnormal communication between the peripheral bronchial tree and pleural space which can further also open to the skin surface. It is associated with significant morbidity and mortality in addition to poor quality of life. Management requires a multidisciplinary approach with careful evaluation to choose the best approach to treatment.

A 36-year-old male presented with a left chest wall tumor with multiple surgeries and CT revealing a left apico-posterior segment broncho pleural cutaneous fistula. Various options for the management of the BPCF including surgery and bronchoscopic occlusion were considered however an IR approach was planned. Plan was for vascular plug occlusion with/without glue embolization of the apico-posterior segmental bronchus. A 6F sheath was placed under direct vision and a 12 mm CERA plug was deployed. After plain plug occlusion, there were no signs of air leak. Various options for management including surgery and bronchoscopy procedures are limited in patients with poor pulmonary reserve. The IR approach offers the advantage of doing the procedure under real-time fluoroscopy, and no airway compromise. However, literature describes the use of glue to seal the interstices of the device which if not sealed was a cause of recurrence later. In our case, we report the percutaneous use of a CERA vascular plug as the sole device, especially since it has a polytetrafluoroethylene (PTFE) membrane which ensures occlusion, in addition to its titanium nitride coating which improves epithelialization. This ensures sustained occlusion as the sole agent, unlike other devices including the Amplatzer vascular plug.

This highlights the relatively easy percutaneous route and the first report of CERA vascular plug usage for managing a case of broncho pleural cutaneous fistula.