Ann Thorac Surg 2000;70:301-302
© 2000 The Society of Thoracic Surgeons
Case report
Intrathoracic fibrin sealant application using computed tomography fluoroscopy
Patrick J. O’Neill, PhD, MDa,
Heidi L. Flanagan, BSNc,
Michael C. Mauney, MDb,
William D. Spotnitz, MDb,c,
Thomas M. Daniel, MDb,c
a Department of General Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
b Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
c Tissue Adhesive Center, University of Virginia Health System, Charlottesville, Virginia, USA
Address reprint requests to Dr Daniel, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Box 310, Charlottesville, VA 22908
e-mail: tmd5m{at}virginia.edu
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Abstract
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Persistent intrathoracic airspace and bronchopleural fistula remain a problem following lung resection or in patients with severe bullous disease experiencing a spontaneous pneumothorax. Although fibrin sealant has been used successfully to manage such air-leaks, precise nonoperative intrathoracic application is difficult. This report describes a novel technique using computed tomography fluoroscopy for catheter-directed FS application through a previously placed thoracostomy tube. Continuous computed tomography-fluoroscopy images allowed real-time catheter manipulation for precise placement of fibrin sealant.
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Introduction
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A persistent intrathoracic airspace with a refractory bronchopleural fistula (BPF) is a difficult surgical challenge. This most commonly occurs following lung resection or in a patient with severe bullous disease who experiences a spontaneous pneumothorax. Obliteration of the airspace and sealing of the BPF remain a prerequisite for healing. Fibrin sealant has emerged as a useful tool in cardiac and thoracic surgical practice [1]. Although intraoperative application of fibrin sealant to visceral surfaces has been utilized for BPF, precise nonoperative application can be difficult. This report describes a novel real-time technique using the new technology of computed tomography (CT)-fluoroscopy [2] to guide fibrin sealant placement via an existing thoracostomy tube.
A 59-year-old male with severe bullous emphysema had a spontaneous right pneumothorax treated with tube thoracostomy and pleurodesis. He developed a recurrent right pneumothorax requiring thoracoscopic talc pleurodesis. Postoperatively, a persistent air-leak was present for almost 2 weeks despite an intraoperatively placed 32-French right thoracostomy tube. When the patient was placed in the standard supine position of a Picker PQ 6000 spiral CT scanner equipped with the Continuous CT system (Picker International, Highland Heights, OH), images demonstrated severe bullous disease and a persistent right anteroapical airspace with the existing thoracostomy tube lying superiorly (Fig 1A, arrow).
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Fig 1. (A) Computed tomographic image of the upper chest demonstrating severe bullous disease (arrow) and a right thoracostomy tube containing the delivery catheter. (B) Following the administration of fibrin sealant, note the resultant fibrin sealant plug (arrow) and the obliteration of the airspace.
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As a treatment option, after informed consent was obtained, fibrinogen (36 mg/ml; 36 ml volume) prepared by the cryoprecipitate method [3] was obtained from the University of Virginia Blood Bank, and bovine thrombin (1,000 units/ml) was obtained from the pharmacy. Cefazolin (1 gm) was reconstituted with sterile water and used as the diluent for the thrombin. A "Y-Type" catheter extension set (Baxter Interlink System, Deerfield, IL) with a male luer lock adapter was attached to two syringes, one containing the fibrinogen, and the other the thrombin. This was connected to an application catheter (Duplocath Application catheter, Baxter Healthcare, Glendale, CA) designed to deliver two non-homogenous solutions simultaneously in parallel. The length of the delivery catheter was measured and cut to extend approximately 3 cm past the end of the indwelling thoracostomy tube (Fig 2).
The application device with the attached syringes of thrombin and fibrinogen was advanced through the povidone iodine-prepped thoracostomy tube until the tip of the catheter was seen in the pleural space (Fig 1A, arrow). Under continuous CT-fluoroscopy, the fibrinogen and thrombin were simultaneously applied. Real-time imaging confirmed obliteration of the pulmonary blebs with a sealant plug (Fig 1B, arrow). The thoracostomy tube was then reattached to water-seal and approximately 3 minutes were allowed for polymerization of the sealant. The previous air-leak slowly decreased over the next 36 hours and the chest tube was successfully removed. A chest roentgenogram prior to discharge demonstrated no air-fluid levels or pneumothorax, and the patient experienced no complications prior to his 2-month follow-up visit.
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Comment
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Persistent BPF is associated with increased morbidity and length of stay [1]. Conservative management dictates thoracostomy tube placement and awaiting spontaneous closure of the air-leak. In this case, both conservative measures and thoracoscopic talc pleurodesis had failed.
Fibrin sealant is a dual-component biological adhesive whose action mimics the final stage of clotting whereby fibrinogen (in the presence of factor XIII, thrombin, and calcium) polymerizes to form a fibrin clot, which is gradually absorbed by fibrinolysis [4]. The fibrin plug promotes tissue sealing by filling empty spaces, although the volumes of sealant needed to fill intrathoracic spaces may have to be limited due to the cost of the adhesive. Fibrin sealant can be applied by transbronchial, topical, or percutaneous routes to close BPF, reinforce staple lines, or fill persistent intrathoracic spaces [1, 5, 6]. Video-assisted thoracoscopic placement [6] as well as CT-guided percutaneous transthoracic application [5] of fibrin sealant have been used to seal pulmonary air-leaks. The drawback to these techniques is the need for additional invasive procedures.
This report describes a novel technique utilizing a new advance in real-time computed tomography known as CT-fluoroscopy. Using this new modality, real-time catheter manipulation and precise placement of the fibrin sealant allowing for accurate closure of the fistula was possible. This unique application of CT-fluoroscopy resulted in the successful treatment of this difficult, but very common, clinical problem. Although risks include the introduction of infection and embolization of adhesive into the tracheobronchial tree, this technique adds to the armamentarium of the thoracic surgeon when faced with persistent BPF and incomplete approximation of pleural surfaces. Further investigation into the use of this modality is warranted.
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Acknowledgments
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The authors thank Bryan S. Landtrip, MD, and Karl K. Wallace, Jr, MD, for radiologic support, and Lynne Mayers, PhD for editorial support.
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References
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Accepted for publication November 22, 1999.
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Abstract
Introduction
