A Successful and Novel Approach to Pleurodesis of Alveolar-Cutaneous Fistula via CT Guided Autologous Blood Patch Injection

Abstract

INTRODUCTION: A novel approach to pleurodesis in alveolar-cutaneous fistula using autologous blood patch injection under CT guidance is discussed in our case report. CASE PRESENTATION: 89 year old male presented to the hospital with 3 week history of progressive dyspnea. The past medical history was significant for laryngeal carcinoma status post laryngectomy , severe COPD on home oxygen and coronary artery disease. Medications included inhaled bronchodilators, Lisinopril, simvastatin and aspirin. He was afebrile with a blood pressure of 160/73, heart rate of 63, respiratory rate of20 and oxygen saturation of 94% on 50% oxygen via tracheal collar. Breath sounds were diminished on the left hemithorax, along with a dull note to percussion. Laboratory evaluation was unremarkable except for elevated BNP at 873. Admission chest X-ray revealed moderate sized left-sided effusion. Appropriate treatment was initiated for COPD exacerbation and decompensated heart failure. Despite aggressive diuresis, the dyspnea and pleural effusion persisted. A thoracentesis with removal of 1 L of straw colored fluid was done. As the patient developed a pneumothorax following thoracentesis, a leftsided pigtail catheter was placed with improvement of patient's symptoms. Within 24 hrs of removal of the chest tube, the patient developed significant subcutaneous emphysema, which progressed rapidly to involve his neck, face ,abdomen and lower extremities. The peri-orbital swelling was so severe that the patient could not open his eyes. Chest X-ray revealed significant bilateral subcutaneous emphysema with pneumomediastinum and left sided pneumothorax . CT of the chest confirmed the above findings, in addition to identifying an alveolar-cutaneous fistula connecting a large subpleural bulla to the chest wall. As there was an enlarging left sided pneumothorax, a 28 Fr chest tube was placed with egress of large amount of air. His hospital course was complicated with Clostridium difficile colitis, sepsis and renal failure. As the patient was a poor surgical candidate, an autologous blood patch pleurodesis was done by the attending pulmonologist. This involved injection of 60 cc of the patient's own blood into the site of pleural defect under CT guidance using a 19-gauge coaxial needle under local anesthesia and moderate sedation. The subcutaneous emphysema and air leak improved dramatically following this procedure, although the patient died of complications of renal failure as the patient and family did not want to pursue hemodialysis. DISCUSSION: Broncho/alveolar cutaneous fistulas can occur after pulmonary surgery ,traumatic or spontaneous pneumothorax or as a complication after tube thoracostomy drainage. Repair of the defect via video assisted thoracoscopy or open thoracotomy is the ideal treatment. However alternative treatment options such as autologous blood patch pleurodesis could be considered in poor surgical candidates. In this procedure, blood is obtained from the patient via venipuncture into a tube containing no anticoagulant and immediately injected into the pleural defect. This causes direct sealing of the site of leak via formation of a patch of clotted blood (i.e., fibrin), followed by inflammation and scarring which causes pleurodesis. Sclerosing agents such as talc and Doxycycline are less favored due to increased pain and dense adhesions . Introduction of infection during the procedure is a concern ,which can be minimized with adherence to strict aseptic techniques. CONCLUSIONS: Autologous blood patch pleurodesis has been previously done via intrapleural drain for post-lobectomy air leaks. To our knowledge, this is the first report of such a procedure done under CT guidance, which enables accurate identification and closure of the pleural defect. This procedure is safe, simple, effective and of particular value in poor surgical candidates.