Supplementary Material for: Pulmonary Lobar Torsion Following Bronchoscopic Lung Volume Reduction with Endobronchial Valves: A Case Report

Introduction: Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) is an effective and minimally invasive alternative to lung volume reduction surgery for some patients with severe emphysema. While generally well-tolerated, it may lead to rare but serious complications. Pulmonary lobar torsion and secondary infarction is a known postoperative complication after thoracic surgery but has not been previously reported following BLVR.

Case presentation: A 70-year-old woman with chronic obstructive pulmonary disease (COPD) underwent EBV placement in the right upper lobe, with a good lung function and clinical improvement. Fifteen months after placement, she presented with epigastric pain, haemoptysis, and respiratory distress. Imaging revealed a torsion of the right upper lobe, initially misinterpreted as pneumonia, which necessitated an urgent thoracotomy and lobectomy. Intraoperative and histopathological findings were compatible with the diagnosis of lobar torsion with ischemic necrosis.

Conclusion: This case presents the first reported pulmonary lobar torsion following EBV treatment. The clinical presentation can be nonspecific or with misleading symptoms, potentially leading to diagnostic delays. Clinicians should be aware of such complication in patients with previous BLVR presenting with new or unexplained clinical findings. Imaging and early surgical intervention are critical to prevent life- threatening complications.