Endobronchial Watanabe spigot is a device used to occlude bronchus for a variety of indications, including hemoptysis. However, its placement could be difficult, especially if the source of bleeding is the upper lobes. To facilitate its placement, we introduce a new technique using a guidewire and a custom-made spigot.
A 65-year-old man with a history of left upper lobe adenocarcinoma presented with a respiratory distress from a massive hemoptysis, despite a recent arterial embolization of the left bronchial artery. Computed tomography scan of the chest demonstrated a large left upper lobe tumor surrounded by ground-glass opacity suggesting alveolar flooding (Fig. 1). Flexible bronchoscopy localized the bleeding from the apical segment of the left upper lobe.
In an effort to manage the hemoptysis in an emergent manner, we decided to occlude the bronchus using the Endobronchial Watanabe spigot (EWS; Novatech, La Ciotat, France), as a bridge to repeat arterial embolization. To facilitate the spigot insertion, in this difficult location, we used a novel technique by initially placing a guidewire (Jagwire 0.035×4.5 m; Boston Scientific, Natick, MA) into the bleeding bronchus. We used a custom-made EWS, with a 1 mm channel in its long axis, which we slide up the bronchus on the guidewire under bronchoscopic guidance. Once located at the uptake of the apical segment, the spigot was easily pushed forward using a flexible forceps inserted through the working channel of the bronchoscope. (Fig. 2, online supplement video, Supplemental Digital Content, http://links.lww.com/LBR/A112). This technique produced immediate cessation of the bleeding allowing adequate hemodynamic and respiratory stability for a repeat embolization of the right bronchial and the left subclavian arteries. The spigot was removed 24 hours following the embolization without an incident.
Life-threatening moderate or massive hemoptysis is frequently encountered in the practice of interventional pulmonology.1 Different therapeutic approaches are available for the palliation of the hemoptysis. Among them, bronchial artery embolization (BAE) is the most effective approach. However, the procedure cannot always be performed on an emergent basis and requires patients to be hemodynamically stable and with adequate oxygenation. Besides, the required expertise may not be universally available. On occasion, the procedure could lead to major complication of spinal stroke. Bronchoscopic techniques do have their place in early management of moderate to massive hemoptysis and in stabilizing the cardiopulmonary status of the patient. Several bronchoscopic therapeutic techniques are available for the purpose. If the source of bleeding is endoscopically visible, local hemostasis can be achieved using either laser photocoagulation, argon plasma coagulation, electrocautery, or any of the tamponade methods. In the cases of hemoptysis where the source of bleeding is peripheral, the strategy is to identify the involved segmental bronchus and instill hemostatic agent such as cold saline, epinephrine, tranexamic acid, fibrinogen/thrombin combination, or to seal the segment using either silicone spigot, cyanoacrylate glue, or oxidized regenerated cellulose.2
In our case, poor respiratory status of the patient mandated a rapid intervention starting with a diagnostic flexible bronchoscopy. The latter did not reveal any endobronchial lesion. Thus, we opted for sealing the apical segment of the upper lobe, the source of bleeding, with a custom-made silicone spigot. The device, designed by Watanabe, was initially used for air leaks, especially for bronchopleural fistulas.3–5 This concept has also been extend to the temporary management of moderate to massive hemoptysis by occluding involved bronchial segment as a bridge to BAE or a definitive surgery.6,7 In a retrospective study, Bylicki et al8 reported immediate success in over 80% of the patients when such a strategy was utilized.
In our experience, however, endobronchial placement of the spigot is not always easy, particularly in the context of emergency and instability of the patient. The anatomy of the bronchial tree makes it difficult to place the spigot in the upper lobes. To overcome this difficulty, we customized the spigot with a 1 mm channel through its long axis to accommodate appropriate size guidewire.
In this particular patient we inserted the guidewire through the working channel of a flexible bronchoscope, and anchored it into the bleeding bronchial segment. The bronchoscope was then removed, leaving the guidewire in place. To prevent accidental dislodgement, the guidewire was gently pushed forward by an assistant at the proximal end of the working channel of the bronchoscope while gradually withdrawing the scope through the endotracheal tube. The bronchoscope was then reinserted alongside the guidewire, to confirm its position. A flexible biopsy forceps was inserted through the working channel of the bronchoscope and once out of the distal end, it secured the spigot previously inserted over the guidewire. The spigot was then gradually pushed over the guidewire until it reached and occluded the involved bronchial segment. Once the spigot was in the satisfactory position the guidewire was removed. The procedure instantaneously stopped further bleeding. No bleeding was noticed through the 1 mm channel of the spigot. The spigot was kept in place for 24 hours after the definitive procedure of BAE.
In our opinion, this technique is a simple, swift, effective, and inexpensive strategy to facilitate spigot insertion in difficult anatomic location in the management of moderate to massive hemoptysis. We did not require fluoroscopic guidance during the procedure; however, if required, it could further facilitate the spigot insertion. Further experience is required.
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