Impact of Anastomotic Airway Complications After Lung Transplantation

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Impact of Anastomotic Airway Complications After Lung Transplantation Sudish C. Murthy, MD, PhD, Eugene H. Blackstone, MD, Thomas R. Gildea, MD, Gonzalo V. Gonzalez-Stawinski, MD, Jing Feng, MS, Marie Budev, DO, David P. Mason, MD, Gösta B. Pettersson, MD, PhD, Atul C. Mehta, MD The Annals of Thoracic Surgery Volume 84, Issue 2, Pages 401-409.e4 (August 2007) DOI: 10.1016/j.athoracsur.2007.05.018 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Anastomotic airway complications after lung transplantation. Cumulative number of events per patient is depicted from repeating-events analysis. Each symbol is an event, vertical bars are asymmetric 68% confidence limits (CL) equivalent to ± one standard error, and numbers in parentheses are patients remaining at risk. Solid line is parametric estimate enclosed within dashed 68% CLs. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Instantaneous risk (hazard function) of necrosis-related (top line) and obstruction-related (bottom line) anastomotic airway complications after lung transplant. Solid lines are parametric estimates enclosed within dashed 68% confidence limits. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Probability of occurrence of one anastomotic airway complication after lung transplantation and recurrence of a second and third event. Each symbol represents an occurrence, vertical bars are 68% confidence limits (equivalent to ± one standard error), and numbers in parentheses are patients remaining at risk. Solid lines are parametric estimates enclosed within dashed 68% confidence limits. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Anastomotic airway complications after lung transplantation, formatted as in Fig 1, stratified by telescoping versus end-to-end technique. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Impact of anastomotic airway complications and their treatment on survival after lung transplantation. Format is as for Fig 3. Open circles represent survival before occurrence of complications (competing-risk modulated renewal analysis), closed circles are survival after a treated anastomotic airway complication, and squares are survival after an untreated complication. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Patient management algorithm for anastomotic airway complications, based on this reported experience. (*Resolved necrosis event may proceed to obstruction; **for example, ablation, dilatation, silicon stent placement; ***mildly symptomatic obstructions may be closely observed, particularly if the complication is malacia. BPF = bronchopleural fistula; SEMS = self-expanding metallic stents.) The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 1 Indication for transplant. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 2 Bronchoscopic images of anastomotic airway complications: partial or full-thickness necrosis. (A) Necrosis of right single lung transplant airway. (B) Suspected early dehiscence with suture eroding into airway. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 3 Bronchoscopic images of anastomotic airway complication: obstruction. (A) Obstruction from eccentric granulation tissue stenosis. (B) Obstruction from cicatricial fibrosis. (C) Obstruction from bronchomalacia. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 4 Necrotic (circles) and obstructive (squares) anastomotic airway complications after lung transplantation. Cumulative number of events per patient is depicted from repeating-events analysis. Each symbol is an event, vertical bars are asymmetric 68% confidence limits (CL) equivalent to ± one standard error, and numbers in parentheses are patients remaining at risk. Solid lines are parametric estimates enclosed within dashed 68% CLs. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 5 Anastomotic airway complications within 24 months of lung transplantation according to date of operation. Solid line is parametric temporal trend enclosed within dashed 68% confidence limits (equivalent to ± one standard error). The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 6 Relation of height mismatch to occurrence of obstructive complications within 24 months of lung transplantation. Format is as for Appendix Fig 5. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Appendix Fig 7 Proportion of complications treated according to date of their occurrence. Filled circles are grouped prevalence, and solid curve is the temporal trend estimate. The Annals of Thoracic Surgery 2007 84, 401-409.e4DOI: (10.1016/j.athoracsur.2007.05.018) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions