Bronchoscopic Localization of a Post‐Surgical Persistent Air Leak Facilitating Successful Treatment With a Hybrid Imaging‐Guided Percutaneous Sealing of Fistula and Autologous Blood Patch Technique

ABSTRACT

Post‐surgical persistent air leak (PAL) poses significant management challenges in patients with high surgical risk and complex anatomy. A 58‐year‐old female with advanced thymoma underwent extensive thoracic resection and developed PAL refractory to conservative management with pleural drain insertion. Chest Computed Tomography (CT) suggested a possible broncho‐pleural fistula at the left lower lobe superior segment. Sequential bronchoscopic balloon occlusion under general anaesthesia localized the fistula to the LB6 lateral subsegment with the aid of a digital chest drain system. This was confirmed by methylene blue instillation via bronchoscopy and observation of colour change in the pleural drain fluid. Interventional radiology (IR) subsequently performed CT‐fluoroscopy guided percutaneous sealing of fistula using Histoacryl‐lipiodol mixture, followed by autologous blood and thrombin instillation via the pleural drain, resulting in obliteration of fistula and complete resolution of PAL. We highlight a unique case of multi‐disciplinary collaboration between Pulmonology and IR to successfully treat PAL via a combination of minimally invasive techniques.

In this case of a complex post‐surgical PAL after radical thymectomy, lobectomy and pleurectomy, we describe how sequential bronchoscopic balloon catheter occlusion with the aid of a digital chest drain allowed physiological localization of an air leak predominantly originating from the LB6 lateral subsegment. This allowed our Interventional Radiology colleagues to perform a highly targeted and precise CT‐guided percutaneous sealing of a fistula that resolved the air leak. This unique multidisciplinary strategy expands therapeutic options for high‐risk patients where reoperation is not feasible.

1. Introduction

Persistent air leak (PAL) complicates up to 26% of pulmonary resections and contributes to morbidity, prolonged hospital stays, and higher healthcare costs [1, 2]. When conservative drainage fails, there is no clear consensus on optimal management [1, 3]. Surgical repair carries considerable risks in patients with limited physiological reserves. Bronchoscopic and interventional radiology (IR) techniques have emerged as effective minimally invasive alternatives [1, 2]. However, precise anatomical localization of PAL is essential before any targeted therapy. CT may suggest the anatomical site of a fistula but cannot confirm the functional culprit due to collateral ventilation [4]. We describe a case of recurrent post‐surgical PAL following extensive thoracic resection for advanced thymoma, successfully managed through combined bronchoscopic localization and a hybrid imaging‐guided percutaneous sealing of fistula followed by intra‐pleural autologous blood and thrombin injection.

2. Case Report

A 58‐year‐old female with Stage IVA thymoma received neoadjuvant chemotherapy followed by radical surgery comprising left posterolateral thoracotomy, resection of anterior mediastinal mass, left upper lobectomy, left radical pleurectomy, lymph node dissection, resection and reconstruction of the diaphragm and pericardium. Intra‐operatively, multiple air leaks were surgically repaired. Three pleural drains were placed at the conclusion of surgery (basal, anterior apical and posterior apical). The basal drain was removed on post‐operative day (POD) 4, and anterior apical on POD 7. On POD 10, there was no air leak detected from the digital pleural drain (Thopaz+, Medela AG, Baar, Switzerland) even with coughing, and the posterior apical drain was clamped overnight. Chest X‐rays (CXR) performed on POD 11 prior to and 2 hours (h) after the final drain removal showed a stable small left hydropneumothorax. She was discharged asymptomatic. On POD 12, she presented with acute dyspnea. CXR performed appeared stable compared to POD 11. Given her worsening symptoms, a CT Pulmonary Angiogram was performed which excluded pulmonary embolism but showed a moderate to large left‐sided loculated hydropneumothorax. A 16 French pleural drainage catheter was placed on POD 13 and initial air leak on the digital chest drain was 80 mL/min. Once the air leak was 0 mL/min, the drain was clamped for 24 h and removed on POD 22 with a stable CXR prior to and 4 h after removal. She unfortunately re‐presented on POD 36 with an overnight history of transient pleuritic chest pain but persistent dyspnea. CXR showed left hydropneumothorax recurrence (Figure 1a). CT‐guided pleural drain was performed and subsequent observation recorded persistent daily air leak averaging 100–300 mL/min, that did not improve unlike during the previous admission. Repeat CT (POD 42) showed that the left lower lobe superior segmental bronchus (LB6) was abutting the pleural surface, suspicious for a broncho‐pleural fistula (Figure 1b).

FIGURE 1.

(a) Chest radiograph performed on admission (POD 36) depicting a large left hydropneumothorax. (b) Sagittal section of CT Thorax performed on POD 42 after recurrence of post‐operative hydropneumothorax despite pleural drain management demonstrating atelectatic left lower lobe with suggestion of left lower lobe superior segmental bronchus reaching close to the pleural surface signifying a possible broncho‐pleural fistula (indicated by green arrow). (c) Cessation of air leak to 0 mL/min on the digital chest drain after balloon occlusion of the LB6 lateral subsegment. (d) Instillation of methylene blue at LB6 lateral segment resulted in a change in colour in the drain tubing fluid, confirming the localization of the air leak at LB6 lateral subsegment. (e) Localization assisted IR in performing targeted percutaneous sealing of fistula under CT Fluoroscopic guidance.

Under general anaesthesia, sequential bronchoscopic balloon catheter occlusion was performed on POD 44. Occlusion of the LB6 orifice reduced air leak from 300 mL/min to 10 mL/min. Subsegmental testing revealed reductions to 40 mL/min (LB6 medial) and complete cessation at 0 mL/min (LB6 lateral) (Figure 1c), localising LB6 lateral as the predominant contributor of the PAL. Occlusion of the anterior, lateral and posterior basal segments did not significantly improve the air leak. Methylene blue instillation into LB6 lateral resulted in blue discoloration of the pleural drain fluid, providing confirmatory evidence (Figure 1d). During the period whereby the patient was treated, endobronchial valves (EBVs) were temporarily unavailable. Guided by our bronchoscopic localization, the IR team proceeded to perform a hybrid procedure of imaging‐guided targeted percutaneous sealing of fistula followed by autologous blood and sealant injection in a single procedure on POD 47 to maximise the chances of air leak resolution. The LB6 lateral pleural surface was targeted with a 20G needle and embolized with histoacryl glue‐lipiodol mixture (1:1 ratio) using a combination of CT and fluoroscopy imaging. 120 mL of autologous blood drawn via venepuncture was then injected into the existing pleural drain followed by a mixture of human clottable protein and human thrombin (EVICEL, Johnson and Johnson, New Jersey, USA) (Figure 1e). The air leak subsequently ceased completely on POD 50, and the drain was removed on POD 52. A 3‐month follow up CT and 12‐month follow up CXR continued to demonstrate complete resolution (Figure 2).

FIGURE 2.

(a) CT image on POD 13 showing loculated hydropneumothorax when the patient presented with acute symptoms following discharge after surgery. (b) CT obtained 3 months after discharge following bronchoscopic localization and percutaneous fistula obliteration procedure showing no recurrence of air leak.

3. Discussion

PAL is common after upper lobe resections or in patients with incomplete fissures or emphysema [3]. While pleural drain insertion is established as first‐line conservative therapy, varying opinions exist on second‐line management, especially amongst high‐risk surgical patients [1, 2, 3]. Precise localization is critical for successful minimally invasive treatment. Imaging alone may be misleading due to the presence of collateral ventilation, whereby airflow from adjacent segments continues to supply the leak site [4]. Bronchoscopic balloon occlusion offers real‐time functional mapping, precisely identifying culprit segments and avoiding ineffective or excessive interventions [2]. In this case, CT suggested LB6 involvement, but physiological testing further identified the LB6 lateral subsegment as the predominant site of air leak. Once localized, bronchoscopic methods like EBV deployment or IR‐based therapeutic options are available. Cyanoacrylate‐lipiodol mixtures polymerize rapidly, allowing durable sealing of focal fistulas [1, 2]. Compared with bronchoscopic fibrin sealants—which can degrade or displace under airflow [1]—CT guided percutaneous fistula sealing provides highly controlled, targeted therapy [2]. This modality is particularly useful for distal or anatomically challenging fistulas, as in our patient. When balloon occlusion is inconclusive, adjuncts like methylene blue, segmental insufflation, collateral ventilation assessment systems and continuous digital drain monitoring can provide further functional confirmation [1, 2, 3]. This case highlights a unique multidisciplinary approach in a circumstance whereby EBV was unavailable. Bronchoscopic physiological localization precisely identified the leaking segment, enabling IR to deliver definitive therapy via imaging‐guided percutaneous sealing of the fistula. This combined approach offers a safe, effective and minimally invasive alternative for complex PAL in patients unsuitable for further surgery.

Author Contributions

Ivory Ching Yee Yeo, Eugene MingJin Gan and Carrie Kah‐Lai Leong contributed to the conceptualization, writing and editing of the manuscript. Eugene MingJin Gan and Carrie Kah‐Lai Leong were involved in the care of the patient.

Funding

The authors have nothing to report.

Disclosure

No AI tools were used to generate clinical content or data. All conceptualization and manuscript preparation were undertaken solely by the authors.

Consent

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images using the form provided by the Journal.

Conflicts of Interest

The authors declare no conflicts of interest.

Yeo I. C. Y., Leong C. K.‐L., and Gan E. M., “Bronchoscopic Localization of a Post‐Surgical Persistent Air Leak Facilitating Successful Treatment With a Hybrid Imaging‐Guided Percutaneous Sealing of Fistula and Autologous Blood Patch Technique,” Respirology Case Reports 14, no. 8 (2026): e70711, 10.1002/rcr2.70711.

1. Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.