What are the possible airway complications of lung transplantation?

Updated: Aug 19, 2019
  • Author: Bryan A Whitson, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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A systemic arterial supply is not established at the time of lung transplantation surgery. Viability of the anastomosis depends on collateral flow from the pulmonary circulation. For end-to-end anastomoses, the use of an omental, pericardial, or intercostal muscle anastomotic wrap in the early postoperative period has reduced the incidence of ischemia-induced airway necrosis and dehiscence.

More recently, many institutions have switched to a procedure that does not require a wrap procedure, one that uses a telescoping anastomosis. Nonetheless, procedures that employ wrapping with pericardium or some other tissue still are performed occasionally. In the telescoping anastomosis, the membranous (ie, outer) portion of the donor bronchus is sutured end-to-end to the recipient bronchus, but the cartilaginous inner portion is inserted into the recipient bronchus for 1 or 2 cartilaginous rings. The internal margin of the anastomosis is not sutured and may result in an endoluminal flap.

Diaphragmatic dysfunction resulting from phrenic nerve paralysis is uncommon (fewer than 4% of cases).

Bronchial dehiscence

Bronchial dehiscence is the most common anastomotic airway complication in the early postoperative period. It occurs in 2-3% of cases. Ischemia at the anastomotic site is the major factor in the development of this complication. Dehiscence probably is best assessed by bronchoscopy; however, CT scans typically demonstrate the presence of extraluminal gas, which is 100% sensitive and 72% specific for dehiscence. Patients with telescoping anastomoses also may develop small anastomotic diverticula, which appear as smooth rounded air collections at the inferior-medial aspect of the anastomosis.


Anastomotic stricture occurs in approximately 10% of cases, and the risk for stenosis may be increased with a telescoping anastomosis. Stenoses often manifest with progressive airflow obstruction that can be difficult to differentiate from other causes, such as acute rejection or bronchiolitis obliterans syndrome. Stricture probably is best evaluated by bronchoscopy; however, CT scans often demonstrate the area of narrowing. Treatment is stenting, typically with an expandable metallic stent. More recently, balloon dilatation has obviated the need for stents in some centers.

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