A 34-year-old man with cystic fibrosis underwent bilateral lung transplantation six months ago. He 
now presents with dyspnea and a wheeze. Bronchoscopy reveals a tight anastomotic stricture of 
the left bronchial anastomosis. The best initial management option is

A. endoscopic dilation and insertion of a stent.
B. endoscopic injection of the stenotic area with steroids.
C. endoscopic laser ablation of the stricture.
D. left pneumonectomy.
E. sleeve resection of the stenotic bronchial anastomosis. 

Answer A

Airway complications following lung transplantation occur in 5-15% of the patients (1). Omental wraps and avoidance of steroids were initially thought to be prerequisite to successful airway anastomoses following lung transplantation. Currently, the omentum is rarely used and moderate-dose postoperative steroids are often used. Factors thought to be important in anastomotic complications include ischemia, excessive length of the donor bronchus, preoperative steroid use, acute allograft rejection, prolonged postoperative ventilation, and anastomotic technique (2). 

Initial management usually includes rigid bronchoscopy with dilation using either pediatric bronchoscopes, gum-tipped bougies, or a balloon dilator. Dilation alone often fails, so a stent is usually inserted to maintain airway potency. Endobronchial stents are available in sets of different diameters and lengths. Silicone stents must be placed through a rigid bronchoscope, and they are thick-walled and relatively rigid. Expandable wire stents are thin-walled with moderate flexibility, and they can be placed through a flexible bronchoscope.

Steroid injection has not been reported to be effective in lung transplant airway stenoses. Nd-YAG laser treatment of limited areas of granulation tissue build-up has been reported to be effective, but treatment of late strictures with Nd-YAG laser alone usually leads to recurrent stenosis. Pneumonectomy is not an appropriate management option. Sleeve resection of a stenotic bronchus has been reported after lung transplantation, but it is associated with substantially greater morbidity than bronchoscopic management of airway stenosis (3).


Date H, Trulock EP, Arcidi JM, Sundaresan S, Cooper JD, Patterson 
GA. Improved airway healing after lung transplantation. J Thorac Cardiovasc Surg 
1995;110:1424-33.
We evaluated various clinical factors to identify predictors of airway complication after 
lung transplantation. Two hundred twenty-nine consecutive single (n = 110) and bilateral (n = 
119) lung transplants were done between September 1988 and August 1994. These 348 bronchial 
anastomoses were retrospectively analyzed. Airway complication that necessitated clinical 
intervention affected 33 anastomoses (9.5%) in 29 patients (12.8%). Satisfactory healing was 
achieved in 22 of these patients by conservative therapy such as one or a combination of 
dilation, stent, and laser. There were five deaths (2.2%) attributable to airway complications. 
One patient had an early postoperative death unrelated to airway complication and one patient has 
a recalcitrant bronchus intermedius stricture. Complication occurred more often in single-lung 
than in bilateral lung transplants (16/110, 14.4%, versus 17/238, 7.1%; p < 0.05). The use of a 
mattress suture (21/153, 13.7%) was associated with more frequent complications than was simple 
interrupted suture (8/122, 6.6%) or figure-of-eight suture (4/73, 5.5%) (p < 0.05). For patients 
in whom airway complications subsequently developed, the duration of postoperative mechanical 
ventilation was greater than that for those in whom an airway complication did not develop. The 
prevalence of airway complications as our program evolved was evaluated by separating the 229 
transplants into three groups: phase I, the first 77 transplants; phase II, the next 76 
transplants; and phase III, the most recent 76 transplants. The airway complication rate per 
anastomosis was significantly lower in phase III (5/126, 4.0%) than in phase I (12/110, 10.9%; p 
< 0.05) and phase II (16/112, 14.3%; p < 0.01). The majority of airway complications are 
successfully treated and rarely fatal. The recent reduction in prevalence of airway complications 
is likely a result of better maintenance immunosuppression and rejection surveillance.

Shennib H, Massard G. Airway complications in lung transplantation. Ann Thorac Surg 
1994;57:506-11.
This article reviews the literature on airway healing after lung transplantation. From a 
historical point of view, this has been the Achilles' heel of lung transplantation through two 
decades, from the first attempt at single-lung transplantation in 1963 to the clinical successes 
in the early 1980s. The overall incidence of lethal airway complications is estimated to be 2% to 
3%, whereas that of late stricture is 7% to 14%. Comparison of experiences has been difficult 
without a universal classification; a new classification for airway and anastomotic complications 
and healing is proposed. Ischemia appears to be the most important factor influencing airway 
healing. Low-pressure collateral bronchial blood flow from the pulmonary artery may be affected 
by low cardiac output, reperfusion edema, or rejection; mucosal injury may be further increased 
by prolonged positive-pressure ventilation. Good bronchial healing appears to be possible without 
a protective wrap and with early use of steroids. The management of bronchial complications is 
challenging and requires endoscopic skills including knowledge of endobronchial laser 
photocoagulation and stent insertion techniques.

Schafers, HJ, Shafer M, Zink C, Haverich A, Borst HG. Surgical treatment of airway complications 
after lung transplantation. J Thorac Cardiovasc Surg 1994;107;1476-80.
The treatment of dehiscence or stenosis of the bronchus after lung transplantation has to 
date consisted of endobronchial stenting or balloon dilation. Operative intervention has been 
limited to retransplantation with all its limitations. In our series of 121 anastomoses at risk, 
severe bronchial stenosis occurred in 11 (9%). In five instances the airway complications were 
treated surgically: two patients underwent retransplantation, one patient had a bilobectomy, and 
two required sleeve resection of the stenotic segment. All these procedures successfully removed 
the stenosis. This experience demonstrates that options other than bronchial anastomotic stenting 
and dilation may be successfully used to overcome posttransplantation anastomotic complications. 
Conventional resections may result in superior long-term graft function compared with 
retransplantation, avoiding the immunologically adverse effects of the latter procedure.