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A Novel Method for Insertion of the Straight Metallic Tracheal Stent
A Novel Method for Insertion of the Straight Metallic Tracheal Stent Kuruswamy Thurai Prasad, MD, DM, Babu Ram, MS, Inderpaul Singh Sehgal, MD, DM, Sahajal Dhooria, MD, DM, and Ritesh Agarwal, MD, DM Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
A straight metallic tracheal stent can be inserted either during flexible or rigid bronchoscopy. However, in patients with significant airway obstruction or those requiring tumor debulking, rigid bronchoscopy is the method of choice. A tracheoscope size 12 or larger is generally required for the introduction of the straight metallic tracheal stent. Herein, we describe a novel
method that facilitates the introduction of the straight metallic tracheal stent through a size 8.5 tracheoscope by using the introducer tube of the silicone stent applicator.
C
(Fig 1A). Flexible bronchoscopy showed extrinsic compression and infiltration of the upper trachea, causing approximately 90% obstruction (Fig 1B). Rigid bronchoscopy and insertion of a straight metallic tracheal stent was planned for the relief of airway obstruction. After induction of anesthesia with propofol and fentanyl, intubation was attempted with a size 12 Storz (internal diameter [ID] 12 mm) tracheoscope. However, owing to marked glottic edema, intubation was unsuccessful. The patient was subsequently intubated with a size 8.5 rigid tracheoscope (ID 10.5 mm). Inasmuch as simultaneous insertion of the metallic stent assembly and the Hopkins telescope into the size 8.5 tracheoscope was not possible, we decided to insert the metallic stent using a silicone stent applicator. The straight, covered, metallic tracheal stent (Ottomed Bravo, Mitra & Co., New Delhi, India), 18 60 mm, with an outer diameter (OD) of 6.5 mm (Fig 2A) was first directly deployed within the introducer tube of the silicone stent applicator (TONN stent applicator set, Green, OD 10.25 mm, Novatech, France) (Figs 2B, 2C, 2D). The Hopkins telescope was then inserted into the introducer tube (Figs 3A, 3B). The entire assembly was then inserted into the rigid scope (Fig 3C). The introducer tube was positioned within trachea under direct vision in such a manner that its tip was beyond the stenotic segment. The Hopkins telescope was removed, and the stent was then deployed by inserting the pusher into the introducer tube while simultaneously withdrawing the introducer tube and the tracheoscope (Fig 3D). The position of the stent was then confirmed with flexible bronchoscopy (Fig 1C). The patient was successfully extubated the next day. A lateral roentgenogram of the neck a week later showed the tracheal stent in proper position (Fig 1D).
entral airway obstruction (CAO) is a life-threatening condition most commonly caused by malignant conditions such as carcinoma of the lung, esophagus, or thyroid [1]. Placement of a self-expanding metallic stent (SEMS) in the airway is an effective palliative treatment for CAO due to extrinsic compression and tracheal infiltration [2]. Deployment of a SEMS in the airway can be performed either during flexible or rigid bronchoscopy. However, in patients with significant airway compromise and in those requiring tumor debulking, flexible bronchoscopy may be difficult and potentially dangerous [1]. In such circumstances, rigid bronchoscopy with a larger tracheoscope (12 mm, to accommodate both the stent assembly and the optical telescope) is the preferred method because the patient can be ventilated while other interventions are being carried out. In certain situations, where intubation with a large tracheoscope is not possible and the patient has critical airway obstruction, the options are limited. Herein, we describe a novel method for deploying metallic stents through a smaller barrel of a rigid bronchoscope.
Technique A 45-year-old woman presented to the emergency department with stridor of 1 week’s duration. Six months earlier, she had undergone total thyroidectomy, followed by radioiodine therapy for papillary carcinoma of thyroid. On examination, she had a heart rate of 110 beats/minute, respiratory rate of 32 breaths/minute, and oxygen saturation of 92% while breathing 40% oxygen. A large mass (about 10 6 cm) was located on the anterior aspect of her neck. A lateral roentgenogram of the neck showed marked narrowing of the upper trachea by the tumor Accepted for publication April 11, 2016. Address correspondence to Dr Agarwal, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2016;102:e379–81) Ó 2016 by The Society of Thoracic Surgeons
Comment Airway stenting with SEMS is a commonly used palliative procedure for patients with malignant CAO [3–6]. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.04.047
e380
HOW TO DO IT PRASAD ET AL METALLIC TRACHEAL STENT
Ann Thorac Surg 2016;102:e379–81
Fig 1. (A) Lateral roentgenogram of neck showing tumor in the anterior aspect of neck, causing marked narrowing of upper trachea. (B) Flexible bronchoscopic view showing extrinsic compression and infiltration of upper trachea by polypoidal growths, causing approximately 90% obstruction of trachea. (C) Flexible bronchoscopic view showing metallic tracheal stent in position, completely relieving the airway obstruction. (D) Lateral roentgenogram of the neck showing relief of obstruction by the tracheal stent.
SEMS can be deployed with either the flexible or the rigid bronchoscope. During flexible bronchoscopy, the stent is deployed over a guidewire under direct bronchoscopic visualization [3, 4]. With a rigid bronchoscope, the stent assembly can be directly introduced through its barrel and deployed under direct vision of the optical telescope [5, 6]. In patients with CAO and severe hypoxemia, rigid bronchoscopy is the preferred method. Rigid bronchoscopy provides several benefits compared with flexible bronchoscopy, including uninterrupted ventilation, better ability to suction blood and respiratory secretions, performance of additional endobronchial interventions like tumor debulking, and easier manipulation of the stent for optimal positioning. The introduction of a SEMS during rigid bronchoscopy requires a larger rigid bronchoscope (ID 12 mm)
because of the need to accommodate both the stent delivery system (OD 6–9 mm) and the Hopkins telescope (outer diameter 4.5 mm). However, this may not be possible in all patients. In our patient, intubation was difficult because of distortion and edema of the upper airway caused by to the neck mass. Hence, a small rigid tracheoscope (size 8.5) was used. Although the stent delivery system could have been introduced through the size 8.5 tracheoscope, confirmation of proper positioning of the stent would have required either fluoroscopy, which was not available to us, or an ultrathin bronchoscope (OD 2.8 mm) or an optical telescope (OD 2.8-2.9 mm). During use of the ultrathin bronchoscope or optical telescope, there is always a risk of damage to these delicate equipments when the stent assembly is passed alongside it. By using our method, one can ensure
Fig 2. (A) Metallic stent with its applicator. (B) Introducer tube and pusher of the silicone stent applicator (Tonn applicator, Green, outer diameter 10.25 mm). (C, D) Metallic stent being deployed inside the introducer tube.
Ann Thorac Surg 2016;102:e379–81
HOW TO DO IT PRASAD ET AL METALLIC TRACHEAL STENT
e381
Fig 3. (A) Introducer tube (with metallic stent within it) and Hopkins telescope placed through it. (B) Loaded metallic stent within the introducer tube viewed through the Hopkins telescope. (C) Introducer tube and pusher passing through the size 8.5 rigid tracheoscope (Storz, inner diameter 10.5 mm). (D) Deployment of metallic stent with pusher.
proper positioning of the stent even without these facilities. In conclusion, in situations where intubation with a large rigid bronchoscope is not possible because of a difficult airway, our novel method is likely to be extremely useful for the deployment of straight metallic stents.
References 1. Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169: 1278–97.
2. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J 2002;19:356–73. 3. Lin SM, Lin TY, Chou CL, et al. Metallic stent and flexible bronchoscopy without fluoroscopy for acute respiratory failure. Eur Respir J 2008;31:1019–23. 4. Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: longterm outcomes analysis. Chest 2003;124:1993–9. 5. Madan K, Dhooria S, Sehgal IS, et al. A multicenter experience with the placement of self-expanding metallic tracheobronchial Y stents. J Bronchology Interv Pulmonol 2016;23:29–38. 6. Ranu H, Madden BP. Endobronchial stenting in the management of large airway pathology. Postgrad Med J 2009;85: 682–7.
A straight metallic tracheal stent can be inserted either during flexible or rigid bronchoscopy. However, in patients with significant airway obstruction or those requiring tumor debulking, rigid bronchoscopy is the method of choice. A tracheoscope size 12 or larger is generally required for the introduction of the straight metallic tracheal stent. Herein, we describe a novel
method that facilitates the introduction of the straight metallic tracheal stent through a size 8.5 tracheoscope by using the introducer tube of the silicone stent applicator.
C
(Fig 1A). Flexible bronchoscopy showed extrinsic compression and infiltration of the upper trachea, causing approximately 90% obstruction (Fig 1B). Rigid bronchoscopy and insertion of a straight metallic tracheal stent was planned for the relief of airway obstruction. After induction of anesthesia with propofol and fentanyl, intubation was attempted with a size 12 Storz (internal diameter [ID] 12 mm) tracheoscope. However, owing to marked glottic edema, intubation was unsuccessful. The patient was subsequently intubated with a size 8.5 rigid tracheoscope (ID 10.5 mm). Inasmuch as simultaneous insertion of the metallic stent assembly and the Hopkins telescope into the size 8.5 tracheoscope was not possible, we decided to insert the metallic stent using a silicone stent applicator. The straight, covered, metallic tracheal stent (Ottomed Bravo, Mitra & Co., New Delhi, India), 18 60 mm, with an outer diameter (OD) of 6.5 mm (Fig 2A) was first directly deployed within the introducer tube of the silicone stent applicator (TONN stent applicator set, Green, OD 10.25 mm, Novatech, France) (Figs 2B, 2C, 2D). The Hopkins telescope was then inserted into the introducer tube (Figs 3A, 3B). The entire assembly was then inserted into the rigid scope (Fig 3C). The introducer tube was positioned within trachea under direct vision in such a manner that its tip was beyond the stenotic segment. The Hopkins telescope was removed, and the stent was then deployed by inserting the pusher into the introducer tube while simultaneously withdrawing the introducer tube and the tracheoscope (Fig 3D). The position of the stent was then confirmed with flexible bronchoscopy (Fig 1C). The patient was successfully extubated the next day. A lateral roentgenogram of the neck a week later showed the tracheal stent in proper position (Fig 1D).
entral airway obstruction (CAO) is a life-threatening condition most commonly caused by malignant conditions such as carcinoma of the lung, esophagus, or thyroid [1]. Placement of a self-expanding metallic stent (SEMS) in the airway is an effective palliative treatment for CAO due to extrinsic compression and tracheal infiltration [2]. Deployment of a SEMS in the airway can be performed either during flexible or rigid bronchoscopy. However, in patients with significant airway compromise and in those requiring tumor debulking, flexible bronchoscopy may be difficult and potentially dangerous [1]. In such circumstances, rigid bronchoscopy with a larger tracheoscope (12 mm, to accommodate both the stent assembly and the optical telescope) is the preferred method because the patient can be ventilated while other interventions are being carried out. In certain situations, where intubation with a large tracheoscope is not possible and the patient has critical airway obstruction, the options are limited. Herein, we describe a novel method for deploying metallic stents through a smaller barrel of a rigid bronchoscope.
Technique A 45-year-old woman presented to the emergency department with stridor of 1 week’s duration. Six months earlier, she had undergone total thyroidectomy, followed by radioiodine therapy for papillary carcinoma of thyroid. On examination, she had a heart rate of 110 beats/minute, respiratory rate of 32 breaths/minute, and oxygen saturation of 92% while breathing 40% oxygen. A large mass (about 10 6 cm) was located on the anterior aspect of her neck. A lateral roentgenogram of the neck showed marked narrowing of the upper trachea by the tumor Accepted for publication April 11, 2016. Address correspondence to Dr Agarwal, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India; email: [email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2016;102:e379–81) Ó 2016 by The Society of Thoracic Surgeons
Comment Airway stenting with SEMS is a commonly used palliative procedure for patients with malignant CAO [3–6]. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.04.047
e380
HOW TO DO IT PRASAD ET AL METALLIC TRACHEAL STENT
Ann Thorac Surg 2016;102:e379–81
Fig 1. (A) Lateral roentgenogram of neck showing tumor in the anterior aspect of neck, causing marked narrowing of upper trachea. (B) Flexible bronchoscopic view showing extrinsic compression and infiltration of upper trachea by polypoidal growths, causing approximately 90% obstruction of trachea. (C) Flexible bronchoscopic view showing metallic tracheal stent in position, completely relieving the airway obstruction. (D) Lateral roentgenogram of the neck showing relief of obstruction by the tracheal stent.
SEMS can be deployed with either the flexible or the rigid bronchoscope. During flexible bronchoscopy, the stent is deployed over a guidewire under direct bronchoscopic visualization [3, 4]. With a rigid bronchoscope, the stent assembly can be directly introduced through its barrel and deployed under direct vision of the optical telescope [5, 6]. In patients with CAO and severe hypoxemia, rigid bronchoscopy is the preferred method. Rigid bronchoscopy provides several benefits compared with flexible bronchoscopy, including uninterrupted ventilation, better ability to suction blood and respiratory secretions, performance of additional endobronchial interventions like tumor debulking, and easier manipulation of the stent for optimal positioning. The introduction of a SEMS during rigid bronchoscopy requires a larger rigid bronchoscope (ID 12 mm)
because of the need to accommodate both the stent delivery system (OD 6–9 mm) and the Hopkins telescope (outer diameter 4.5 mm). However, this may not be possible in all patients. In our patient, intubation was difficult because of distortion and edema of the upper airway caused by to the neck mass. Hence, a small rigid tracheoscope (size 8.5) was used. Although the stent delivery system could have been introduced through the size 8.5 tracheoscope, confirmation of proper positioning of the stent would have required either fluoroscopy, which was not available to us, or an ultrathin bronchoscope (OD 2.8 mm) or an optical telescope (OD 2.8-2.9 mm). During use of the ultrathin bronchoscope or optical telescope, there is always a risk of damage to these delicate equipments when the stent assembly is passed alongside it. By using our method, one can ensure
Fig 2. (A) Metallic stent with its applicator. (B) Introducer tube and pusher of the silicone stent applicator (Tonn applicator, Green, outer diameter 10.25 mm). (C, D) Metallic stent being deployed inside the introducer tube.
Ann Thorac Surg 2016;102:e379–81
HOW TO DO IT PRASAD ET AL METALLIC TRACHEAL STENT
e381
Fig 3. (A) Introducer tube (with metallic stent within it) and Hopkins telescope placed through it. (B) Loaded metallic stent within the introducer tube viewed through the Hopkins telescope. (C) Introducer tube and pusher passing through the size 8.5 rigid tracheoscope (Storz, inner diameter 10.5 mm). (D) Deployment of metallic stent with pusher.
proper positioning of the stent even without these facilities. In conclusion, in situations where intubation with a large rigid bronchoscope is not possible because of a difficult airway, our novel method is likely to be extremely useful for the deployment of straight metallic stents.
References 1. Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169: 1278–97.
2. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society. Eur Respir J 2002;19:356–73. 3. Lin SM, Lin TY, Chou CL, et al. Metallic stent and flexible bronchoscopy without fluoroscopy for acute respiratory failure. Eur Respir J 2008;31:1019–23. 4. Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: longterm outcomes analysis. Chest 2003;124:1993–9. 5. Madan K, Dhooria S, Sehgal IS, et al. A multicenter experience with the placement of self-expanding metallic tracheobronchial Y stents. J Bronchology Interv Pulmonol 2016;23:29–38. 6. Ranu H, Madden BP. Endobronchial stenting in the management of large airway pathology. Postgrad Med J 2009;85: 682–7.