Lung transplantation remains the only definitive therapy for selected patients with end-stage respiratory failure. Unique to lung transplantation, the donor graft is dependent on retrograde pulmonary arterial circulation and is therefore vulnerable to ischemia. This ischemic susceptibility underlies airway complications, which remain a significant source of morbidity and mortality.1
The International Society for Heart and Lung Transplantation standardized definitions and grading criteria to improve interstudy comparisons, classifying airway complications as ischemic necrosis, anastomotic dehiscence, bronchial stenosis, and bronchomalacia.2 A large meta-analysis with more than 50,000 lung transplantation recipients reported a pooled airway complications incidence of 12.5%, with significant impact on mortality.3
Pertinent risk factors identified were pretransplant hospitalization, a diagnosis of COPD (relative to cystic fibrosis), restrictive lung disease, bilateral lung transplantation (vs single), right-sided anastomosis (vs left), telescopic anastomosis (vs end-to-end), prolonged mechanical ventilation, severe primary graft dysfunction, and acute rejection.3 Pretransplant corticosteroids, immunosuppressants, or antifibrotic therapy did not demonstrate consistent association with airway complications.4
Bronchial stenosis is the most common clinically significant airway complication and a recent cohort demonstrated increased risk with colonization of Pseudomonas aeruginosa and other gram-negative organisms.1 Among the airway complication phenotypes, anastomotic dehiscence carries the highest risk, with 30-day mortality approaching 60%.3 Conversely, bronchial stenosis has not consistently translated into worse overall survival. This suggests that timely intervention may mitigate long-term impact.5 Nevertheless, airway complications are independently associated with increased mortality, underscoring the importance of early recognition and structured management.4
Management is predominantly bronchoscopic and phenotype-driven. For bronchial stenosis, balloon bronchoplasty is first-line therapy and often yields immediate symptomatic and physiologic improvement. Restenosis is common, necessitating repeat procedures. While experience with spray cryotherapy is promising, particularly in refractory stenosis, the literature remains limited to small series and anecdotal reports, underscoring the need for rigorous prospective data.6 Paclitaxel-coated balloons are an emerging therapeutic option in managing refractory nonanastomotic bronchial stenosis, and there is currently a clinical trial (OXYGEN-RCT) underway.7
Airway stenting is reserved for refractory stenoses, complex anatomy, bronchomalacia, or mixed phenotypes. Emerging technologies—like custom, 3-D printed stents tailored to patient-specific anatomy—have demonstrated feasibility and improved airflow in small series, particularly in irregular or multifocal stenoses and vanishing bronchus syndrome.8 Although long-term durability data remain limited, these innovations highlight the expanding role of interventional techniques in transplant airway management.
Airway complications remain consequential and potentially lethal after lung transplantation. A multidisciplinary approach with tailored bronchoscopic therapy enables early detection of ischemia and stenosis before clinical deterioration. Integration of standardized grading systems with phenotype-directed interventional algorithms may prevent progression to severe complications and reduce associated morbidity and mortality. Continued refinement of surgical technique, peri-operative optimization, infection control, and bronchoscopic innovation will be essential to improving long-term graft survival.
References
1. Perch M, Hayes D Jr, Cherikh WS, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-ninth adult lung transplantation report—2022; focus on lung transplant recipients with chronic obstructive pulmonary disease. J Heart Lung Transplant. 2022;41(10):1335-1347. doi:10.1016/j.healun.2022.08.007
2. Crespo MM, McCarthy DP, Hopkins PM, et al. ISHLT consensus statement on adult and pediatric airway complications after lung transplantation: definitions, grading system, and therapeutics. J Heart Lung Transplant. 2018;37(5):548-563. doi:10.1016/j.healun.2018.01.1309
3. Huang J, Lin J, Zheng Z, et al. Risk factors and prognosis of airway complications in lung transplant recipients: a systematic review and meta-analysis. J Heart Lung Transplant. 2023;42(9):1251-1260. doi:10.1016/j.healun.2023.04.011
4. Kapnadak SG, Ramos KJ, Flodin R, et al. Airway complications after lung transplantation: perioperative risk factors and clinical outcomes. JHLT Open. 2025;9:100315. doi:10.1016/j.jhlto.2025.100315
5. Coppolino A, Woehl E, Connolly EM, et al. Bronchial stenosis after lung transplant: risk factors and clinical outcomes. J Heart Lung Transplant. 2025;44(4):S165. doi:10.1016/j.healun.2025.02.334
6. Ratwani AP, Lentz RJ, Chen H, et al. Spray cryotherapy for benign large airway stenosis: a multicenter retrospective cohort study of safety and practice patterns. J Bronchology Interv Pulmonol. 2024;31(1):63-69. doi:10.1097/LBR.0000000000000930
7. Greer M, Fuehner T, Warnecke G, et al. Paclitaxel-coated balloons in refractory nonanastomostic airway stenosis following lung transplantation. Am J Transplant. 2014;14(10):2400-2405. doi:10.1111/ajt.12845
8. Sawal N, Pennington KM, Petrossian R, et al. Custom silicone Y-stents for the management of anastomotic stenosis in lung transplant recipients. Respir Med. 2024;231:107737. doi:10.1016/j.rmed.2024.107737
