A 61-year-old man who had been diagnosed with nonspecific interstitial pneumonia underwent left LT from a brain-dead donor under peripheral cardiopulmonary bypass support due to secondary pulmonary hypertension. Because of the fragility of the recipient’s pulmonary artery (PA) and antithrombotic therapy for the cardiopulmonary bypass, refractory bleeding from the anastomosis was difficult to control during the operation even using a fibrin sealant patch (TachoSil®; Takeda Pharmaceutical Company Limited, Tokyo, Japan). Therefore, a nonabsorbable local hemostatic agent (Hydrofit®; Sanyo Chemical Industries, Kyoto, Japan) usually used in aortic surgery was applied to seal the bleeding site on the left PA. This hemostatic agent successfully stopped the bleeding; however, it later resulted in encapsulation and stenosis of the PA anastomosis, which was managed by two balloon dilation procedures [3]. The patient developed no airway complications during his hospitalization and was finally discharged 3 months postoperatively in a stable condition.
Although he had been clinically well without any pulmonary infection or rejection after discharge, he reported a sudden decrease in his forced expiratory volume in 1 s at 1 year 2 months after LT. Bronchoscopic examination revealed what appeared to be a white foreign body protruding into the left main bronchus distal to the bronchial anastomosis (Fig. 1). It was easily removed with a bronchoscopic biopsy forceps, and the patient’s pulmonary function recovered to his baseline. This apparent foreign body appeared to be the hemostatic agent used during his LT. The pathological finding revealed eosinophilic or amphophilic amorphous structure infiltrated by inflammatory cells. The patient developed the same symptom 3 months later, and he was again successfully treated with bronchoscopic removal of a similar foreign body. One month later, however, he eventually developed hemoptysis, suggestive of a bronchopulmonary artery fistula. Contrast-enhanced chest computed tomography showed a foreign body located in the mediastinum between the left main bronchus and the left main PA, partially protruding to the left main bronchus (Fig. 2). He was urgently admitted to our hospital, and an operation for reconstruction of the bronchus and the left PA was planned.
The operation was performed as follows. With the patient in the supine position and under general anesthesia, a median sternotomy and left third intercostal transverse incision were performed to approach the left hilum. Tight adhesion was found between the left main bronchus and the left PA anastomosis, where the foreign body was located as shown by preoperative chest computed tomography. For fear of massive hemorrhage, we started cardiopulmonary bypass from superior and inferior vena cava to ascending aorta under systemic heparinization. The foreign body was finally removed gently and thoroughly, revealing a relatively large fistula and several tiny fistulas that had spread over the bronchial wall distal to the anastomosis (Fig. 3a–c). These fistulas were closed directly with simple sutures under extracorporeal cardiopulmonary support. We initially replaced the PA with a homograft; however, because of the fragility of the homograft, we eventually exchanged the PA with a vascular graft (Triplex®; Terumo Corporation, Tokyo, Japan). A pectoralis major muscle flap was introduced between the bronchus and the left PA to separate these structures (Fig. 3d). Cardiopulmonary bypass was switched to peripheral extracorporeal membrane oxygenation from right femoral vein to right femoral artery before finishing the operation. The patient was managed in the intensive care unit for about 2 months after the surgery. Although several reoperations were needed for postoperative bleeding, thrombosis in the vascular graft, and a refractory chest wound infection, the patient was eventually discharged 5 months postoperatively. Five months later after discharge, chest computed tomography showed no abnormalities and occlusion on the left bronchus and reconstructed left pulmonary artery (Fig. 4).