|Year : 2006 | Volume
| Issue : 2 | Page : 92-97
Dallah Hospital, Chest Department, P.O. Dallah Hospital, Chest Department, P.O.Box - 87833, Riyadh, Saudi Arabia, Pulmonary Medicine Department, Alexandria, Egypt,
Dallah Hospital, Chest Department, P.O.Box - 87833, Riyadh, Saudi Arabia
| Abstract|| |
Bronchial stents are mostly used as a Palliative relief of symptoms often caused by airway obstruction, It is also used for sealing of stump fistulas after pneumonectomy and dehiscence after bronchoplastic operations. Advances in airway prosthetics have provided a variety of silicone stents, expandable metal stents, and pneumatic dilators, enabling the correction of increasingly complex anatomical problems. Several series have been published describing the application and results of these techniques. This manuscript reviews the historical development of stents, types, indication, outcome, and complications. Alternative therapies for tracheobronchial stenting were also reviewed
Keywords: Stent, bronchial, airway obstruction
|How to cite this article:|
Ibrahim E. Bronchial stents. Ann Thorac Med 2006;1:92-7
More than 80% of patients with lung cancer are unsuitable for curative surgical treatment. Palliative relief of symptoms, often caused by airway obstruction, is possible. More than 50% of patients with advanced stage lung cancer have stenosis of the central airways. In patients with symptoms, interventional pulmonology is considered as a method of maintaining airway patency. Intraluminal tumors can be resected endoscopically and relief from obstruction achieved by many interventions such as mechanical coring-out of the tumor, laser vaporization, photodynamic therapy, electrocautery, cryotherapy, brachytherapy and stenting., Advances in airway prosthetics have provided a variety of silicone stents, expandable metal stents and pneumatic dilators, enabling the correction of increasingly complex anatomical problems. Several series have been published describing the application and results of these techniques.,, Although the long-term outlook in these cases is often dismal, the temporary or permanent relief of airway obstruction provides significant palliation with marked improvement in quality of life and, in many cases, prolongation of life.
Stents have been extensively used mostly for the management of esophageal to airway fistulas, with malignancy being more common than the congenital or other acquired forms.,,,,, They are also indicated for the sealing of stump fistulas after pneumonectomy and dehiscence after bronchoplastic operations. The goal of the stent is to provide a seal - as tight as possible - in the airway to prevent aspiration and pneumonias. Since there are many types of stents with different properties, the selection of a stent requires considering the type of lesion, its location, the physical characteristics of the stent and its potential short- and long-term complications.
| History and Types of Stents|| |
At present, there are basically two types of stents available: plastic and metallic. The most common of the plastic stents is made of silicone. It is inserted using a special applicator under general anesthesia and rigid bronchoscopy. Since Montgomery described the use of a T-tube in 1965, a variety of silicone stents and prostheses has been described. Dumon introduced his dedicated silicone stent (Dumon stent) in 1990., The Dumon stent has probably been the most commonly used silicone stent. It has external studs at regular intervals or a branched shape to prevent its migration within the airway. However, up to 20% of silicone stents have migrated, with resultant reocclusion, although repositioning or stent removal as many times as needed may be an outstanding advantage for benign tracheobronchial stenosis or slowly growing, frequently recurring tumors.,
Also, up to 15% of all patients with silicone stents develop clinically significant stent obstruction with inspissated secretions due to impairment of mucociliary clearance and impedance of the cough reflex. Furthermore, the thick wall of silicone stents results in a low internal-to-external-diameter ratio such that they cannot be used in smaller airways. Other problems include lack of flexibility in the airway, high mucosal pressure and higher chance of bacterial colonization.
One of the most recent modifications was designed by Freitag (Dynamic Stent, Rüsch, AG Kernan, Germany) and is a silicone Y-stent with the anterolateral walls reinforced with metal hoops. The reinforced silicone posterior wall is collapsible and mimics the dynamics of the membranous trachea during inspiration or expiration., The current generation of airway silicone stents was introduced by Duvall and Bauer and Cooper et al ; they modified the Montgomery T-tube design so that it could be inserted by bronchoscopy. In 1989, Cooper et al reported using a modified silastic T-Y tube for airway problems in 47 patients, including 11 with malignant obstruction. In the late 1980s, airway stents made of metal were developed, such as the Gianturco stent, which consists of a continuous loop of stainless-steel zigzag wire.,
The primary advantage of the expandable metallic stents is their easy delivery by means of fluoroscopy or flexible bronchoscopy under topical anesthesia and their conformability to the airway anatomy due to their self-expanding characteristics. The Gianturco stent, which is made of a continuous zigzag loop of stainless steel wire; and the Palmaz stent, which is a balloon-expandable stent made of stainless steel wire, are now uncommonly used because of their inflexibility and many complications. Wallstents, made of stainless steel wire; and Ultraflex stents, made of a single thread of nitinol wire, are two representative self-expandable metallic stents and have both uncovered and covered versions.,
The advantages of using uncovered expandable metallic stents are their superior mucociliary clearance and low incidence of stent migration. The superior mucociliary clearance with resultant decreased sputum and the low incidence of stent migration occur because only a small area of mucosa is covered by the stent and the metal lattice becomes overgrown with ciliated respiratory epithelium.,, However, uncovered expandable metallic stents have limitations: (1) They are liable to produce progressive tumor ingrowth or granulation tissue through the openings between the wire filaments, (2) they are not suitable for esophagorespiratory fistula and (3) they cannot be removed easily. There is also a potential risk of stent fracture and migration.,
The medical term 'stent' was introduced by Charles R, a British dentist who developed a device that supported the healing of gingival grafts. The term has since been used to refer to any device designed to maintain the integrity of hollow tubular structures.
Indications for stenting included: (1) recurrent benign strictures that were not surgically resectable, (2) active inflammation or edema necessitating acute and possibly temporary support while the pathologic process resolved, (3) rapidly growing or recurrent obstructive endobronchial tumors, (4) tumors producing extrinsic obstruction, (5) early anastomotic strictures that might stabilize over a stent during postoperative remodeling, (6) tracheobronchial malacia and (7) airway fistulas. Because stents are palliative and frequently necessitate ongoing management, they were used only after excluding definitive surgical correction or other more simple endoscopic palliation.
| Clinical Experience of Different Stents|| |
SU et al reported their experience with the use of Dumon silicone stents and self-expandable metallic Ultraflex stents. From July 1999 to December 2003, 10 patients had stent insertion to manage their malignant airway stenosis. All patients had severe respiratory distress. All stents were placed through a rigid Efer-Dumon bronchoscope under general anesthesia. Eight Dumon silicone stents and four metallic Ultraflex stents were placed. There was no death related to stent placement and there were no immediate complications after stenting. Significant improvement of respiratory distress was seen in 9 patients (90%) after stenting. Three stent migrations occurred in 12 stent placements. During follow-up to the present time, 7 patients died of disease progression, with a median survival of 5.2 months (range, 1 to 17.8 months) after stenting. Two patients remain alive, with survivals of 49 and 12 months respectively. They concluded that insertion of the airway stents, either Dumon silicone stents or metallic Ultraflex stents, can provide an effective method to immediately relieve respiratory distress, to improve the quality of life and to prolong survival in patients with malignant central airway stenosis.
Madden et al published their experience with expandable metallic stents. They have deployed 80 expandable metallic stents in 69 patients. They assessed long-term impact of these stents in their patients and reported their experience of 15 patients who have been followed up for more than 1 year after stent insertion. Ten tracheal stents (9 covered, 1 uncovered) and 10 bronchial stents (8 uncovered, 2 covered) were inserted and 5 patients received two stents. Five of these patients experienced no long-term problems. Complications included troublesome halitosis, which was difficult to treat despite various antibiotic regimes; granulation tissue formation above and below the stent that was successfully treated with low-power Nd:YAG laser therapy; and metal fatigue. Some patients receiving endobronchial stenting have episodes of recurrent respiratory tract infection (RTI) early after stent deployment. Bronchoscopy revealed evidence of epithelialization around uncovered ends of covered stents and through uncovered stents. They did not encounter stent migration. They concluded that Ultraflex expandable metallic stents have an important role in the management of selected patients with diverse endobronchial pathologies and are well tolerated in the long term. Although associated granulation tissue can be successfully treated with Nd:YAG laser, halitosis can be a difficult problem to address.
Halitosis proves to be a distressing and difficult complication to resolve. Previous studies have suggested that this condition is secondary to bacterial infection of the stent. Madden et al found that patients with halitosis had covered stents, which may provide a suitable environment for bacterial growth and prevent effective mucociliary clearance. Noppen and colleagues showed that 78% of those receiving mainly silicone stents developed significant airways colonization with bacteria, of which 55% had potentially pathogenic organisms. Their study also found that the most common organisms found were P. aeruginosa, the only potentially pathogenic organism Madden et al found to be present in those patients with halitosis.
Kim et al placed successfully, covered retrievable expandable nitinol stents in nine patients with tuberculous bronchial strictures refractory to balloon dilation. Complications included stent migration (n=1) and tissue hyperplasia at the proximal portion of the stent (n=2). During the follow-up period (5-52 months), stricture recurred in three of five patients (60%) after temporary stent placement for 2 months, whereas stricture did not recur in the other four patients after temporary stent placement for 6 months. Temporary placement of covered retrievable stents appears to be an effective method for the treatment of patients with tuberculous bronchial strictures refractory to balloon dilation.
Low et al investigated the use of interventional bronchoscopic techniques in the management of patients with symptomatic tracheobronchial stenosis from tuberculosis. Those authors evaluated their experience with interventional bronchoscopic techniques in 21 consecutive patients at the Singapore General Hospital, Singapore, from November 1994 to March 2001. All patients underwent rigid bronchoscopy using the Dumon rigid ventilating bronchoscope under general anesthesia. A combination of techniques was used (mechanical or balloon dilatation, Nd-YAG laser and stenting using the Dumon stent). The mean ± SD increase in luminal diameter of the tracheal lesions was from 4.5 ± 2.5 mm pre-procedure to 11.9 ± 1.7 mm post-procedure, whereas that for the mainstem bronchi stenosis was from 2.6 ± 1.0 mm to 8.3 ± 2.4 mm. All patients had immediate relief of symptoms post-intervention. Two patients who presented with acute respiratory failure could be weaned off mechanical ventilation immediately post-procedure. At the end of the study period, 52% (11 out of 21) remained asymptomatic. Bronchoscopic intervention provided immediate symptomatic relief in all of the studied patients. However, repeated sessions may be required to maintain this improvement. It is concluded that interventional bronchoscopic techniques are useful in the management of patients with tracheobronchial stenosis from tuberculosis.
Rieger et al published their experience with a balloon-expandable and a self-expandable stent.
However, few studies have investigated the in vivo properties of different stent types. They implanted 26 balloon-expandable tantanium Strecker stents (18 patients) and 18 self-expandable Wallstents (16 patients) into the tracheobronchial system of 30 patients with combined stenting in 4 patients. Malignant disease was present in 23 patients, benign disease in 7 patients. Both patients and individual stents were monitored clinically and radiographically. Average stent follow-up time was 112 days until explantation and 115 days until patients' death or discharge.
Kaplan-Meier analysis revealed a higher probability for the Wallstent to remain within the tracheobronchial system. Dislocation and compression occurred more rarely. Explantation, however, if desired, was more difficult compared to the Strecker stent. The Wallstent also led to the formation of granulation tissue, especially at the proximal stent end, frequently requiring reintervention. Both stent types proved to be effective therapeutic options in the management of obstructive tracheobronchial disease. The mechanical properties of the Strecker stent seem to be less favorable compared to the Wallstent but removal is easy. For benign disease, however, the Wallstent reveals limitations due to significant side effects.
| New Stents|| |
The Polyflex is a commercially available silastic airway stent with proven efficacy. Due to a smooth outer surface, its anchorage in the airway wall is superficial, which may lead to stent migration. Bolliger et al studied the performance of a newer version of the Polyflex stent with a studded outer surface, which should improve anchorage. In a five-center international study, the new stent was prospectively tested in symptomatic patients with neoplastic central airway stenosis of more than 50% of normal diameter. Insertion technique, efficacy of stent placement and stent-related complications were recorded before and 1 month and 3 months post stent placement. Under general anesthesia and rigid bronchoscopy, 27 stents were inserted in 26 patients. The stents were inserted in the following locations: 10 in right main bronchus, 8 in left main bronchus, 7 in trachea and 2 tracheo-bronchial. There was significant improvement in all functional parameters assessed from before to 1 month and 3 months after stent placement. Stent-related complications were four reversible stent obstructions by secretions, one migration. The observation period was mean 4.3 months (range 2 days to 23 months). The studded Polyflex showed excellent efficacy, was very well tolerated and had a very low migration rate. It presents an improvement over the older smooth model and can be considered a true alternative to the most widely used silastic stent, the Dumon stent.
Surgical options in the treatment of emphysema include lung transplantation and lung volume reduction surgery. Both of these treatment modalities have specific indications and their use is limited to selected patients. Airway bypass via transbronchial fenestration has been shown to improve forced expiratory volume and flow in explanted human emphysematous lungs. Choong et al evaluated the feasibility and safety of in vivo airway bypass stent placement by using a canine model and to assess the influence of topical mitomycin C on the prolongation of stent patency. With dogs under general anesthesia, suitable segmental and subsegmental bronchial wall sites were selected by direct visualization with a flexible bronchoscope. Peribronchial blood vessel injury was avoided by using a Doppler probe. Transbronchial fenestration was formed with a 22-gauge transbronchial needle and the passage was then dilated with a 2.5-mm angioplasty balloon. A balloon-expandable stainless-steel stent (3 mm long × 3 mm wide) with a sleeve of silicone rubber covering was placed within the fenestration. Animals were bronchoscoped weekly to assess stent patency. Seventy stents were placed in 12 dogs. Thirty-five served as controls and the other 35 received transbronchoscopic topical application of mitomycin C once weekly to evaluate the effect on the maintenance of stent patency. Mitomycin C stents were divided into four groups according to the number of treatments: group A, 1 treatment only; group B, 4 weeks; group C, 7 weeks; and group D, 9 weeks. Each once-weekly mitomycin C application consisted of 0.2 ml at a concentration of 1 mg/ml, delivered through a small polyethylene catheter.
Four instances of minor and brief bleeding occurred during stent placement and resolved without incident. One pneumothorax occurred and was treated by chest tube placement, without any adverse sequelae. There was no mortality associated with stent placement. No delayed hemorrhage or pneumothorax occurred. All control stents were occluded at the 1-week follow-up. The median durations of stent patency for group A, group B, group C and group D were 3, 8, 13 and 'greater than 20' weeks respectively. They concluded that airway bypass stent placement could be performed safely. In an animal model, most stents became occluded within 1 week, but topical mitomycin application resulted in significant prolongation of patency.
Tracheobronchial stenting for airway strictures traditionally has been done by using bronchoscopy with or without fluoroscopic guidance while the patient is under general anesthesia. The single most important factor in deciding whether or not to perform airway stenting is the presence of a patent airway distal to the obstruction. Strictures that respond well to treatment, typically, are those due to extraneous compression or intramural pathology. Intraluminal lesions are treated preferentially with ablation because of their tendency to recoil after balloon dilatation and the possibility of rapid tumor ingrowth after stenting.
Raza et al described a percutaneous transtracheal technique of stenting airways that eliminates the need for using general anesthesia and bronchoscopy. Over a 2-year period, seven patients (four men and three women) with a mean age of 59.7 years were referred to interventional radiology for bronchial stenting. All patients had unresectable lung cancer and shortness of breath due to lung collapse distal to the tumor. Overall, 10 stents were placed in seven patients, with three patients receiving more than 1 stent because of the multiplicity of airways involved. Bronchial stenting was technically successful in all patients. All patients experienced symptomatic relief from dyspnea. They concluded that the percutaneous transtracheal approach is a safe and effective option in treating tracheobronchial strictures. The transtracheal technique should be used carefully in patients who have airway strictures proximal to the carina and whether to choose the endoscopic or percutaneous approach should be based on the location of stricture and space available to maneuver wires and catheters if the transtracheal approach is used.
| Outcomes and Complications|| |
Despite the importance and need for placement of bronchial stents in different benign and malignant indications, some complications still occur and the placement needs full attention; but that does not mean panic, as seen by the frequent referral of stable patients with bronchial stents for bronchoscopic evaluation or the foggy question 'Should you remove this stent?' Actually, the most serious is perforation of the bronchial wall. Nouraei et al did report an emergency management of aorto-bronchial fistula 7 years after implantation of a self-expanding metal stent into the left main bronchus. The clinical presentation was characterized by left-sided chest pain, dyspnea and a single bout of hemoptysis. The fistula was surgically managed by aortic resection and primary repair of the aorta and patch repair of the left main bronchus over a Polyflex-covered bronchial stent. When hemoptysis occurs in a patient with a history of bronchial stent implantation, the presence of an aorto-bronchial fistula should be considered. Early diagnosis offers the only possibility of recovery through a lifesaving surgical procedure. Also, stent-related bronchoesophageal fistula was recently reported.
Other complications of metallic airway stents include granulation tissue formation, fracture of struts, migration and mucous plugging. When these complications result in airway injury or obstruction, it may become necessary to remove the stent.
Lemaire et al recently reported their experience with the outcomes of tracheobronchial stents in malignant airway diseases. They planned to identify the short (<30 days) and intermediate (>30 days) benefits and risks of tracheobronchial stents in patients with malignant airway disease. There were 172 stents placed in 140 patients with malignant disease, with no intra-operative mortality. The mean follow-up period was 142 ± 12 days. There were 23 complications, including tumor ingrowth (n=9), excessive granulation tissue (n=7), stent migration (n=5) and restenosis (n=2). Five of the complications occurred during the short-term period (<30 days), with the remaining complications (n = 18) occurring after 30 days. The complications required interventions including laser debridement (n= 14), dilation (n= 4) and stent removal (n=5). They concluded that tracheobronchial stents offer minimally invasive palliative therapy for patients with unresectable malignant central airway obstruction. The benefit of airway stents is particularly seen in the short-term period, where they provide symptomatic improvement and have low complication risk. The major impediment is excessive granulation tissue and tumor ingrowth, which occur primarily after 30 days.
Several representative studies of clinical experience with silicone stents in benign tracheobronchial stenosis have been reported. Patients were treated with plastic stents under rigid bronchoscopy and general anesthesia for benign tracheobronchial stenosis. Most patients had tracheal stenosis following intubation or tracheostomy. All patients had immediate symptomatic relief after stent placement with no procedure-related mortality. It would be ideal to electively remove a stent in patients with benign tracheobronchial stricture after it is no longer needed, because foreign material inserted into the airway would eventually cause complications such as granulation tissue formation. However, there has been much disagreement regarding the optimal time to remove a stent. The important factor is that a tracheobronchial stent should remain in place until a stricture has healed. Stents were removed 18-32 months after placement in 54 patients and no recurrence was reported to occur in 43 patients (80%). Sputum retention was the most common complication (16%), followed by stent migration (10%) and granulation tissue formation (4%).
The studies of clinical experience with silicone stents in malignant tracheobronchial stenosis showed that most patients (94%) had immediate symptomatic relief after stent placement with no procedure-related mortality. Stent migration was less than in benign stenosis and was observed in 6% of patients and stent removal was performed in 8% of patients due to stent migration, pain or associated bronchial aspergillosis. In malignant stenoses, the median survival was 10.6 weeks (8-11 weeks). In malignant pathology, the duration of palliation tends to be limited by the natural history of the disease itself rather than being a direct consequence of stent placement, although the patients' quality of life improved remarkably.
| Alternative Therapies for Tracheobronchial Stenting|| |
Treatment of tracheobronchial obstruction or fistula could be treated by other modalities of bronchoscopic therapy. The bronchoscope could be used in application of laser therapy, brachytherapy , electrocautery, cryotherapy and balloon dilatation to relieve airway obstruction caused by malignant and benign airway lesions. Bronchoscopic treatment of airway malignancies is usually considered in patients with surgically unresectable lesions. The treatment is aimed at relieving obstructive symptoms rather than curing the neoplasm. The majority of bronchoscopic laser therapies are performed using the Nd-YAG laser. Laser therapy can be used to treat both benign and malignant airway tumors that obstruct the major airways. Also, it could be used to close tracheobronchial fistulas and it helps in preparing the airway for insertion of airway stents. Brachytherapy is used to deliver radiation therapy from within the airway lumen to treat malignant tumors that obstruct the airways. The rigid bronchoscope itself can be used as a bougie to dilate malignant or benign airway stenosis. Repeated passage of rigid bronchoscopes of gradually increasing diameters can be used to dilate the trachea and mainstem bronchi. Balloon dilatation through either the flexible or rigid bronchoscope is best suited for stenoses that are short in length and especially if they are intrinsic lesions. Dilatation procedures are more effective if the airway stenosis is intrinsic rather than extrinsic. Bronchoscopic electrocautery employs alternating electrical current to produce coagulation and vaporization of endobronchial lesions. Argon plasma coagulator is also used to accomplish electrocautery therapy. Bronchoscopic cryotherapy consists of cold-induced death of malignant cells by repeated cycles of cold application followed by thawing. Nitrous oxide or liquid nitrogen is most commonly used to produce temperatures of -80°C. Cryoprobes are available for use through rigid or flexible bronchoscopes., Tracheostomy tube could be used to overcome upper airway obstruction. Additionally, laryngeal stenting is used for laryngeal split. Large obstructing airway tumors are suitable for bronchoscopic resection. This is best accomplished with the rigid bronchoscope rather than the flexible instrument. This type of purely palliative therapy provides immediate relief of airway obstruction secondary to large neoplasms in the trachea or main stem bronchi.
| Conclusions and Recommendations|| |
The ideal tracheobronchial stent has not been developed yet. The ideal stent should have the following properties: combines the advantages of silicone and metallic stents; easily inserted and removed; made of a biocompatible material; designed to prevent tumor ingrowth or granulation tissue formation and to maintain mucociliary clearance or to facilitate mucous clearance; can be removed under local anesthesia with conscious sedation; and adapts to the varying airway dimensions without migration during respiration or coughing. Stenting has the outstanding benefit of immediate relief of acute distress from tracheobronchial obstruction within a very short time. Potential developments should include refined removable expandable metallic stents, biodegradable stents and drug-eluting or radioactive-coated stents. Bioabsorbable knitted tubular stents made of poly-llactic acid may be useful to treat major airway stenosis in the child who is growing up year by year, because extraction of the device is unnecessary. Furthermore, mucociliary clearance function is better maintained because the normal airway is preserved after stent resorption. Advances in interventional bronchology, including the bioabsorbable airway stent and improved techniques for placement and removal of tracheobronchial stents may provide definitive alternatives to standard surgical intervention for both malignant and benign airway stenosis in the future.
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