Stent tracheobronchial

Nicholson DA (1998) Tracheal and oesophgeal stenting for carcinoma of the upper esophagus invading the tracheobronchial tree. Clin Rad 53 760-763 Novak Z, Coldwell DM, Mitchell RD, et al. (1999) Percutaneous transgastric placement of esophageal stents. JVIR 10 428-430... 

Patients should be able to cooperate during the procedure. Some patients with severely symptomatic SVCOS may have difficulties in lying flat on the examination table. In these circumstances, the procedure should be undertaken under general anesthesia. A minority of patients will present with simultaneous tracheobronchial narrowing, due to malignant mediastinal compression. Stenting of the airways should precede management of the caval obstruction in such patients. 

There are no dedicated tracheobronchial covered balloon-expandable stents available yet. The Gianturco stent for tracheobronchial application is commercially only provided as an uncovered stent. 

All stents currently available for application in the tracheobronchial system have demonstrated their... 

There are some special indications for stent placement in the tracheobronchial tree. One is the attempted closure of esophagopulmonary fistu-... 

One of the potential advantages of metal stents over the plastic tube stents is the possibility of placement under conscious sedation by flexible endoscopy or fluoroscopy only. However, for a safe and durable access to the tracheobronchial system, the possibility for fine adjustments of the inserted stents, additional therapeutic measures, and permanent control of ventilation, most interventionists prefer to carry out stent implantations under general anesthesia and with the use of a rigid ventilating bronchoscope. Such a setting enables high frequency Venturi jet ventilation. 

After stent insertion, a final completion bronchoscopy with the use of the flexible endoscope should be done to check appropriate stent position, determine patency of bronchial ostia, rule out complications (e.g., bleeding, airway disruption, mucus impaction) and ascertain proper attachment of the proximal and distal stent ends to the tracheobronchial mucosa (see Fig. 12.If). 

The focus of this chapter is primarily on metallic stents. For a detailed overview of the results of placement of plastic tube stents for tracheobronchial obstructions due to malignant tumors, the interested reader is referred to one of the review articles on stenting of the tracheobronchial system written by experienced interventional bronchoscopists (thoracic endoscopist) (Colt and Dumon 1995 Mehta and Dasgupta 1999 Rafanan and Mehta 2000 Wood 2001). 

The Dumon stent is the most widely accepted stent and has become the gold standard by which newer stents are evaluated. Therefore, two large series of Dumon stent placement for tracheobronchial malignancies shall be presented. 

The series from Brescia, Italy reported by Cavaliere et al. comprises 306 patients and placement of 393 silicone stents (Cavaliere et al. 1996). The vast majority of patients were treated with 363 Dumon stents in 27 cases a Y-shaped Hood stent was placed, and in another four cases a Y-shaped Dynamic stent. Stents were inserted into the trachea in 38.7%, right main stem bronchus and bronchus intermedius in 19.8%, left main stem bronchus in 15.5%, trachea and right or left main stem bronchus in 13.5%, and in other positions in 12.5%. Stent insertion resulted in improvement in pulmonary function tests and quality of life in all but six patients (98% success rate). The median survival of patients was 108 days. All patients had malignant tracheobronchial tumors. 

The first report on the oldest metal stent used in the tracheobronchial system was pubUshed by Wallace et al. in 1986 (Wallace et al. 1986). Since then, several studies on the use of this stent type have been pub-hshed and the stent became one of the most frequently applied metal stents in tracheobronchial mahgnancy. Wallace and colleagues initially reported on two cancer patients. Gianturco stents were placed in one to dilate a postoperative bronchial stenosis that caused pneumonia, and in the second to support a tracheal graft that collapsed with respiration. Stents were successfully placed and the patients symptoms improved (Wallace et al. 1986). 

The largest published series of Gianturco stents placed for mahgnant tracheobronchial lesions was published by Wilson and colleagues (1996). A total of 56 patients with incurable mahgnant tracheobronchial tumors (47 bronchial carcinomas and nine metastases) were treated with a total of 117 stents placed in the following locations trachea, 19 left main bronchus, 13 right main bronchus, 10 both main bronchi, 7 trachea and left main bronchus. 

Dasgupta and colleagues (1998) treated 20 patients with neoplastic tracheobronchial strictures with uncovered Wallstents. Stents were successfully deployed in all patients and airway patency was restored. Four patients were successfully weaned after stent insertion, five were receiving mechanical ventilatory assistance, while the remaining died from unrelated causes while receiving mechanical ventilatory assistance. No deaths occurred from stent failure or stent related complications. 

The first publication on the polyurethane covered Wallstent appeared in 1996 (Bolliger et al. 1996). In total, 36 stents were placed in 27 patients with tracheobronchial malignancies. Stent deployment was successful in all patients. The mean dyspnea index improved significantly after stenting, as did the... 

A small series of four patients with malignant tracheobronchial obstruction was presented by Col-REAVY et al. (2000). Stenting was successful in all four patients and led to dramatic relief of stridor. Mean survival was 6 months. One patient died some hours after stent insertion due to bleeding from a site where laser recanalization was carried out, but did not bleed from the stent insertion site. One patient required laser treatment 3 months after stent placement for tumor regrowth. 

A larger patient population was reported by Beer et al. (1999). A total of 27 Palmaz stents were placed in 21 patients with malignant obstructive tracheobronchial obstructions (trachea, n=2 left main stem bronchus, n=8 intermediate bronchus, n=7 right main stem bronchus, n=l lobar bronchi, n=4). Following stent insertion, six patients had no further respiratory distress, and the remaining 15 patients reported relief of dyspnea. In seven patients, postobstructive pneumonia was successfully treated by stent placement. Mean survival time was 12 months. Restenosis occurred in four patients and was treated with redilation in three, and laser ablation in one patient. 

Song and co-workers (1999) placed their self-developed potentially retrievable covered metallic stent in eight patients with tracheobronchial malignant obstructions (esophageal cancer, n=4 lung cancer, n=2 tracheal cancer, n=l gastric cancer, n=l). Stents were successfully placed in all patients but one. In this case a hinged stent (combined tracheal and bronchial stent) was placed too caudal so... 

The group of Colt et al. (1992) were the first to report double stents for carcinoma of the esophagus invading the tracheobronchial tree. Ten patients with severe dyspnea at rest due to airway obstruction ( =5) or esophagorespiratory fistulas (n=5) had tracheal (n=5) or bronchial (n=5) stents placed additionally to the esophageal stent. The tracheobronchial stents were Dumon silicone stents. The fistulas were sealed in all cases. The mean survival time was 121 days (range, 12-350 days). 

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