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A novel approach of management by Amplatz vascular plug for recurrent tracheoesophageal fistula underlying acquired tracheomalacia related to high cuff pressure in an ALS patient

Introduction: Acquired tracheomalacia could develop to Trachoeoesophageal Fistula (TEF) by the damage of tracheal and oesophageal wall secondary to the long term endotracheal or tracheostomy tubes. Most of Amyotrophic Lateral Sclerosis (ALS) patients they need mechanical ventilation support with tracheostomy and commonly experience inappropriate management of tracheostomy tube, leading to complications like tracheomalacia, TEF. Strategies for the TEF management are controversial, but several operations have been preceded. We report a successful case of the novel approach of management for the tracheomalacia with inoperable TEF in ALS patient.

Case presentation: A 62-year-old Asian male patient had tracheostomy after diagnosis of ALS and was supported by 24hrs of mechanical ventilator since 2011. He was diagnosed as tracheomalacia with TEF 2 years later and had primary closure and muscular rotation flap on oesophageal and tracheal defect. Nonetheless, he was diagnosed as the recurrent tracheomalacia with TEF 10 months after the operation. As, the condition of trachea was not enough to endure re-operation, we tried an non-surgical approach using a Amplatzer Vascular Plug II (AVP II, St. Jude Medical, Plymouth, Minnesota, USA) for the TEF closure instead of operation and successfully managed recurred TEF without any complication.

Conclusions: We report a rare care of inoperable recurrent TEF in ALS patient. As recurrent TEF after previous operation should be considered more carefully, using a vascular plug for the management of recurrent inoperable TEF can be considered as treatment of choice especially for the patients who are under vulnerable conditions.

Author(s): Chang Won Kim, Yong Beom Shin, Myung Jun Shin, Je Sang Lee, Jin A Yoon