Nitinol stents in the treatment of benign proximal tracheal stenosis or tracheomalacia

Nitinol stents have been used in the treatment of benign tracheal stenosis. A retrospective review of five patients treated at Stobhill Hospital over the last six and a half years is presented. Age at presentation ranged from 17 to 76 years. The minimum follow-up period was 23 months and the maximum was 78 months. All our patients were successfully decannulated, with none requiring recannulation. Four patients developed granulation tissue related to the stent at intervals ranging from three weeks to 41 months post stenting. Topical mitomycin C application has been useful after resection of granulations using the carbon dioxide (CO2) laser. Stent migration occurred in one patient three weeks after insertion. Nitinol stents are easy to insert and effective in the treatment of tracheal stenosis, but can have associated morbidity. Their use should be considered carefully, as insertion should be regarded as permanent. Publications reporting experience and outcome with the use of Nitinol stents in the trachea are reviewed.     

Endoscopically placed nitinol stents for pediatric tracheal obstruction

OBJECTIVE: To provide preliminary clinical data regarding endoscopically placed nitinol stents for children with tracheal obstruction as a temporizing measure to allow for trach tube decannulation while awaiting growth to allow for tracheal resection. METHODS: This case series describes the experiences of two children (ages 5 and 15) who were dependent upon tracheotomy because of acquired tracheal obstruction. Both patients had combined tracheomalacia and tracheal stenosis. After failing tracheoplasty with rib graft augmentation both patients suffered from extensive tracheal disease, which was too long to allow for immediate tracheal resection. INTERVENTION: Endoscopic placement of nitinol stents in the obstructed tracheal segment using fluoroscopic guidance. All tracheotomy tubes were removed immediately after successful stent deployment with the patient still under general anesthesia. RESULTS: Four stents were placed in total. The first patient's initial stent was too narrow and was, therefore, removed and replaced at a later date with a larger diameter stent. The second patient experienced distal migration of his initial stent requiring stent removal and replacement at a later date. Both patients remain successfully decannulated (follow-up, 25 and 26 months) and are currently living more normal lives as they grow and await tracheal resection. CONCLUSION: Preliminary use of nitinol stents for pediatric tracheal obstruction has enabled successful decannulation in two children with complicated airways. Our results with this series of patients suggest that nitinol stents can be safely used in children as a temporizing measure until tracheal resection can be safely performed. With this approach children can live free from the hassles of trach care, social isolation and peer ridicule. Limited pediatric experience exists in the literature about nitinol stents. Thus, our experience with stent selection and placement will help others avoid problems encountered in this initial series.     

Endoscopically placed expandable metal tracheal stents for the management of complicated tracheal stenosis

BACKGROUND: Metal stents have been advocated to manage complicated tracheal stenosis. OBJECTIVE: The purpose of this investigation is to review the effectiveness of endoscopic placement of tracheal expandable metal stents for complicated tracheal stenosis. METHODS: The charts of 6 patients who have undergone placement of metal expandable stents between 1998 and 2000 were reviewed. RESULTS: Initially, all patients enjoyed immediate palliation of symptomatic tracheal stenosis. Eventually, 4 patients developed significant granulation tissue and/or recurrent stenosis, requiring intervention within 6 months after placement of the stent. One patient required the removal of the stent and placement of a T-tube silicone stent. CONCLUSIONS: Metal stents provide temporary palliation for tracheal stenosis. Metal stents, however, are associated with a high incidence of obstruction with granulation tissue. Their use should be limited to a select group of patients with a short life expectancy (because of other comorbidities) or patients who are not good candidates for reconstructive surgery and/or who refuse or cannot tolerate a tracheotomy.     

Self-expanding metal stents for the management of bronchial stenosis and bronchomalacia after lung transplantation

Background: Airway stenosis or malacia after lung transplantation, usually as a result of anastomotic ischemia, remains a major problem. Methods: The authors report their experience with the Gianturco expandable stent for the management of 23 bronchial stenoses in 18 patients following lung transplantation. Stent placement occurred an average of 5.6 months after transplantation. Results: Stents were well tolerated and produced immediate symptomatic and functional improvement. The mean follow-up after implantation was 21 months (range, 4 to 48 mo). The authors removed five stents by endoscopy and replaced them, and removed one stent entirely. Laser resection was used to control granulomas or partial fibrosis stenosis that occurred in four stents (14.3%) after an average of 4 months. One stent broke but was still in place and effective 32 months later. One patient died of hemorrhage 4 months after stenting. Conclusion: Although it can still be improved, this expandable metal stent is suitable for the treatment of posttransplantation proximal bronchial stenosis.     

The role of endoluminal self-expanding stents in the management of pediatric tracheal stenosis

OBJECTIVE: Review of our experience in the management of pediatric tracheal stenosis using endoscopic techniques and self-expanding intraluminal stents. METHODS: Thirteen children (aged 1 week to 14 years) with various causes of tracheal stenosis were treated. A total of 15 stents were used, 13 self-expanding nitinol stents and 3 silicone self-expanding stents. Follow-up ranged from 6 month to 8 years. RESULTS: There were no stent related mortalities. Serious complications occurred in 4 patients [30.7%] but all were managed successfully. The most frequent problem was granulation tissue formation. Patient follow-up ranged from 6 months to 8 years. In the short-term (18-24 months) 12 stents remained patent and functional. On the longer term (5 years) 3 stents required removal, one required replacement and another resulted in stenosis. CONCLUSION: Endoluminal stenting can have an increasing role in the management of selected cases pediatric tracheal stenosis with acceptable morbidity and stable long-term results.     

Congenital tracheal stenosis

A case of severe congenital tracheal stenosis is presented with reference to the literature on this rare abnormality. The management is described with attention to the need for individually constructed tracheostomy tubes.     

Pediatric tracheal stenosis

Tracheal stenosis is a rare, potentially life-threatening condition described as innate narrowing of the tracheal lumen. The causes of tracheal stenosis vary widely. The most common forms result from prolonged intubation, although congenital causes usually involve complete tracheal rings or compression from cardiovascular malformations. The condition historically has harbored a poor prognosis, but significant advances in radiologic diagnosis, cardiac bypass, and endoscopic and surgical treatments have led to a range of options, better overall survival, and reduced morbidity. The complex, long-term manifestations of tracheal stenosis point to the need for individualized treatment as well as multidisciplinary care.     

Broken Aboulker stents in the tracheal lumen

Aboulker stents (AS) used in laryngotracheoplasty have yielded good results and few complications. Although the complications are few, a potentially serious complication is fracture of the stent. The Aboulker stent produced in France has been used with increasing frequency. Dr. Robin Cotton reported on a method of modifying the stent so that a metal tracheotomy tube could be inserted and wired to the stent. This method avoids the problem of suprastomal tracheal collapse often encountered with other stenting methods. However, though the method is generally effective, transverse break of the AS has occurred in 5 cases in 3 different institutions. When transverse break of the AS occurs, the airway can be compromised rapidly and removal of the stent can be treacherous. During attempts to remove the stent, any tilt of the distal broken segment can cause immediate complete occlusion of the tracheal airway. In this paper, 3 cases of transverse break of the AS are analyzed, and suggestions for avoiding stent breakage are outlined.     

Pharmacotherapy in tracheal stenosis.

From our experience in the treatment of immunological diseases with a tendency to the formation of granulomas, we conceived the idea of treating pharmacotherapeutically the scar-tissue formation in recurrent tracheal stenosis. We have combined two medicines with different modes of action, namely, klorokin and penicillamine. Two patients with recurrent tracheal stenosis have been treated with remarkable results. After several unsuccessful operations it has now been possible to decannulate both of them and enable them to regain a normal way of living.     

气管插管导致气管狭窄的外科治疗

目的分析气管插管导致气管狭窄的临床特征,探讨其治疗方法。方法回顾性分析7例气管插管导致气管狭窄的临床资料,并介绍其治疗方法和疗效。结果实施狭窄气管袖状切除+端端吻合术的7例患者中6例均于术后5个月内拔管,随访3～24个月,未并发喉部狭窄及喉返神经损伤;1例患者因缺血缺氧性脑病死亡。结论气管插管是目前导致气管狭窄最常见的病因之一,正确的手术方法是治愈气管狭窄的重要手段。     

One-stage tracheal reconstruction of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is a condition difficult to manage and associated with a high mortality rate. The principles of one-stage laryngotracheoplasty have been adapted to the surgical management of CTS. Three children underwent a one-stage anterior tracheoplasty with costal cartilage grafting and without cardiopulmonary bypass. Extubation was performed within 13 days. One child developed granulation tissue one month postoperatively, and this was removed endoscopically. The three children were free of respiratory obstruction signs during follow-up ranging from 8 months to 3 years. Postoperative endoscopies have shown growth of the grafted trachea.     

Progressive experience in tracheal stenting with self-expandable stents

We experienced an unacceptably high 21% complication rate with the stainless steel Gianturco stent: a 68-month mean follow-up (range: 37-96 months) of 23 patients revealed three stent fractures and two migrations. Consequently, we began using nitinol mesh stents (Ultraflex) for fibrous stenoses and silicone-covered prostheses (Rush) for proliferative tracheal tumors. The extractable nitinol stent, made from alloy with thermal memory, was palliatively used in 15 patients with fibrous tracheal stenosis; the mean follow-up currently covers 21 months (range: 1-60 months). The silicone-covered prosthesis was used for two patients with inoperable tracheal tumor; follow-up covers 4 months and 2 months, respectively. The prostheses were positioned under visual guidance via the endoscopic approach. The median forced inspiratory volume in 1 s (FIV1) improved from 2.1 l/s (IQR: 0.7-2.4) to 3.2 l/s (IQR: 0.9-3.4) (P=0.018, Wilcoxon signed rank test). The median ratio of peak inspiratory flow (PIF 50%) to peak expiratory flow (PEF 50%) was 1.0 preoperatively (IQR: 0.8-1.5) and 1.8 postoperatively (IQR: 0.6-6.3). Between months 1 and 12, six granulomas developed. Five were treated with antibiotics and steroid aerosol inhalation therapy and one required CO2 laser vaporization. On day 10, one stent migration was observed. The migrated stent was substituted. To date, no stent fracture has been observed. Nitinol and silicone-covered prostheses can be proposed for the palliative treatment of fibrous tracheal stenoses and tracheal tumors, respectively.     

Single-stage tracheal resection for severe tracheal stenosis in older children

OBJECTIVE: While tracheal resection for management of tracheal stenosis is an effective technique that has been well described in adults, the results in children have been less encouraging, as children tolerate anastomotic tension less well than adults. We describe our current technique for the management of severe tracheal stenosis in older children. METHODS: Four teenagers, 16-17 years of age, presented with severe tracheal stenosis. A 16-year-old girl had sustained tracheal stenosis following prolonged intubation, and presented with a severe Grade III stenosis having had 25 endoscopic procedures, and a failed resection at another institute. Two 17-year-old boys and a 17-year-old girl presented with Grade IV stenosis at the suprastomal area following previous intubation injuries. All four children had an identical procedure with tracheal resection over a Hood tracheal stent. RESULTS: All four children were extubated in the operating room. Chin-to-chest sutures were removed between 7 and 10 days, as was the Hood stent. All four are currently asymptomatic with no airway stenosis. CONCLUSIONS: Although tracheal resection for tracheal stenosis in children is associated with a higher failure rate than is seen in the adult population, even severe stenosis and long segment resection may achieve excellent results. We feel that important factors influencing outcome in this series included anastomosis to an intact cricoid ring, and support of the anastomosis with a tracheal stent.