Synchronous Video-Assisted Thoracoscopic Fissure Closure and Endoscopic Lung Volume Reduction Using Endobronchial Valves in a Patient with Less Than 20% Fissure Completeness: A Case Report

Introduction

A successful endoscopic lung volume reduction (ELVR) with endobronchial valves (EBVs) in patients with severe emphysema and hyperinflation can lead to a clinically significant improvement in lung function, exercise capacity, and quality of life.^1–3 However, patients with fissure completeness <80% are typically excluded due to the high likelihood of collateral ventilation (CV).⁴

Recent studies have evaluated the role of video-assisted thoracoscopic surgery (VATS) fissure completion to enable EBV therapy in patients with CV or as rescue treatment after failed ELVR.^5,6 However, no cases have been reported in the literature involving fissure completeness below 20%, likely due to the increased technical difficulty of stapling severely incomplete or fused fissures during VATS.⁷ Here we present a unique case of a single-session VATS-ELVR procedure in a patient with 19% fissure integrity.

Case Report

A 48-year-old woman with a 70 pack-year smoking history presented with dyspnea and limited exercise capacity. Of note, her medical history included cardiac pacemaker implantation at age 2 following interatrial septal defect closure. Despite optimal medical management, pulmonary function tests showed severe hyperinflation and significant self-reported health-impairment (Table 1).

Table 1 Pulmonary Function Test, Exercise Capacity Assessment, Oxygen Requirements and Quality of Life Evaluation Before and After the Combined VATS-ELVR Procedure

CT scan revealed homogeneous emphysema without potential targets for lung volume reduction surgery (LVRS) (Figure 1). Perfusion scan (StratX^® Lung Analysis Platform, Pulmonx, Redwood City, CA, USA) showed predominant parenchymal destruction in the left lower lobe, with fissure integrity below 20% (Figure 2). After multidisciplinary evaluation and detailed discussion involving pulmonologists, transplant specialists, radiologists and thoracic surgeons, a single-session approach combining VATS fissure closure and ELVR of the left lower lobe was proposed to the patient who gave her informed consent.

Figure 1 (A) Chest X-ray at POD 1 and (B) upright chest X-ray at POD 6 after chest tube removal, showing atelectasis of the left lower lobe (LLL); Chest CT scan at baseline (C) and at 3 months postoperative (D) demonstrating homogeneous emphysema and atelectasis of the LLL after the VATS-ELVR procedure, respectively; D upright chest X-ray; POD: postoperative day.

Figure 2 Perfusion scan (StratX® Lung Analysis Platform, Pulmonx, Redwood City, CA, USA) revealing predominant parenchymal destruction in the left lower lobe (gray highlighting indicating 60% voxel density less than −910 HU in the LLL versus 50% in the RLL), with only 19% fissure completeness. Abbreviations: RUL, right upper lobe; RLM, middle lobe; RLL, right lower lobe; LUL, left upper lobe; LLL, left lower lobe; HU, Hounsfield units.

Intraoperative Pulmonary Assessment System (Chartis^®, Pulmonx, Redwood City, CA, USA) evaluation demonstrated the presence of CV (Figure 3). Pleural adhesiolysis and interlobar fissure stapling using the tunnel technique, as described by Decaluwé et al for fissure-first anatomical lung resections, were performed via a triportal VATS approach under general anesthesia using a single-lumen endotracheal tube with a bronchial blocker⁸ Stapling of the fissure was performed using a 60-mm powered Echelon Flex stapler with blue cartridges. No air leaks were detected at the end of the procedure. Two chest tubes were inserted through the trocars incisions. Three Zephyr^® endobronchial valves (Pulmonx, Redwood City, CA, USA) were placed in the left lower lobe after confirming the absence of residual CV.

Figure 3 Intraoperative Pulmonary Assessment before (A) and after (B) surgical stapling of the interlobar fissure via video-assisted thoracoscopic surgery (VATS), confirming the presence of collateral ventilation (CV) prior to fissure closure and its absence following stapling. The horizontal axis represents time (seconds), and the vertical axis represents expiratory volume (mL). The white asterisk (*) indicates Pulmonary Assessment System (Chartis®, Pulmonx, Redwood City, CA, USA) balloon deflation.

The patient had an uneventful recovery with atelectasis confirmed radiologically on postoperative days (POD) 1 and 6 (day of discharge) (Figure 1). Subsequently, she showed significant improvements in quality of life (3-month follow-up), lung function and exercise capacity (3- and 6-month follow-up) (Table 1). Unfortunately, she resumed smoking a few months after the procedure and an unexpected sudden death occurred at 7 months postoperative. Post-arrest chest CT showed no pulmonary abnormalities attributable to the VATS-ELVR procedure. Despite multiple atrial fibrillation episodes recorded by her pacemaker, the exact cause of death remains unclear, though a cardiac origin is favored due to her medical history.

Discussion

This is the first reported case of a single-session VATS fissure closure and ELVR in a patient with only 19% fissure completeness. Although this combined procedure has been used as rescue therapy post EBV placement in patients with ≥80% major fissure integrity, our case suggests that even patients with severely incomplete fissures may benefit from a synchronous hybrid approach.⁵

This strategy could offer several physiological and technical advantages: endotracheal intubation with target lung isolation enables controlled lobar collapse, while VATS adhesiolysis—if needed—can promote faster atelectasis while reducing the risk of parenchymal tearing post-EBV placement. Additionally, chest tube placement decreases the risk of life-threatening pneumothorax, a complication seen in up to 30% of stand-alone ELVR procedures.⁹

This combined approach could expand the pool of patients eligible for lung volume reduction, particularly those who are not candidates for either LVRS or ELVR alone. While current evidence supports this combined strategy mainly as salvage therapy after failed ELVR, the ongoing COMPLETE-1 trial is evaluating its efficacy as an upfront treatment in patients with <95% fissure completeness, with EBV placed during the same session or within 48 hours of VATS fissure closure.^5,10

Limitations of this approach include longer procedural time compared to ELVR or LVRS alone, and VATS-specific complications such as bleeding or prolonged air leak. These can be minimized when the procedure is performed by surgical teams experienced in minimally invasive fissure-first, hilum-last lung resections, particularly in safely stapling incomplete interlobar fissures without injuring pulmonary arteries, veins, or airways, as described in the thoracoscopic tunnel technique for anatomical fissure-first lung resections.⁸ Although chest tubes may contribute to postoperative pain, they might help reduce the morbidity and mortality associated with pneumothorax following EBV placement. Given the limited follow-up period of this case, further studies with longer follow-up are warranted to assess the safety and efficacy of this combined procedure.

Conclusion

Our case suggests that a synchronous VATS–ELVR strategy can effectively eliminate collateral ventilation in carefully selected patients with severe homogeneous emphysema and markedly incomplete fissures who are not considered candidates for standard endoscopic or surgical treatments after thorough multidisciplinary evaluation. When performed in high-volume centers with surgical expertise in thoracoscopic fissure closure, this approach might enable successful lung volume reduction with endobronchial valves even in the setting of less than 20% fissure completeness, leading to meaningful improvements in pulmonary function, exercise capacity, and quality of life.