Ann Thorac Surg 1997;63:1786-1789
© 1997 The Society of Thoracic Surgeons
Case Report
Tracheal Stenosis Treated With Self-Expanding Nitinol Stent
Kazuhiro Yanagihara, MD,
Hiroshi Mizuno, MD,
Hiromi Wada, MD,
Shigeki Hitomi, MD
Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University, Kyoto, Japan
Accepted for publication January 27, 1997.
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Abstract
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A self-expanding nitinol stent was used in 2 patients with inoperable tracheal stenosis due to invasive malignant tumor of the trachea. One was a 70-year-old man with recurrent tumor from adenocarcinoma of the left lung, and the other was a 63-year-old man with recurrent tumor in mediastinal lymph nodes from esophageal cancer. The self-expanding nitinol stent is very useful and effective in inoperable tracheal stenosis due to intraluminal tumor invasion.
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Introduction
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See also page 1789.
Since the first use of an expandable metallic stent for a case of postoperative bronchial stenosis by Wallace and associates in 1986 [1], expandable metallic stents have been inserted for airway stenosis, especially compressive or cicatricial stenosis [2–5]. But in cases of invasive tumor, expandable metallic stents have not been suitable because of the growth of tumor between the wires of the stent [5].
We successfully treated 2 cases of inoperable tracheal stenosis with a self-expanding nitinol stent (SENS; Ultraflex esophageal prosthesis; Boston Scientific Corp, Watertown, MA) designed for treatment of esophageal stenosis [6, 7].
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Material and Methods
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Method of Insertion
A SENS (Fig 1
) was inserted into the trachea under topical anesthesia. The distal side of the tracheal tube was placed at the peripheral side over the tumor under endoscopic investigation. After removal of the sheath, the gelatin coat of the Ultraflex was dissolved with warm, sterile saline solution. The distal end of the stent was ligated with silk thread. Under fluoroscopic guidance the SENS was pushed out through the tracheal tube, while the ligating thread was held with biopsy forceps. Concurrent with the pushing out of the SENS and dilation of the trachea by self-expanding of the stent, the tracheal tube was removed. The silk thread was removed by laser burning.
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Fig 1. . (A) Ultraflex esophageal prosthesis that is stretched, compressed, and encased in gelatin and its proper sheath. (B) Self-expanding nitinol stent after the gelatin has been dissolved with warm, sterile saline solution (after being cut to 4.5 cm). (C) How to insert the self-expanding nitinol stent through a tracheal tube. The self-expanding nitinol stent compressed in the tracheal tube reexpands as soon as it is pushed out through the tube.
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Patient 1
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In October 1995, a 70-year-old man (Fig 2) was referred to our hospital with hemoptysis, wheezing, and dyspnea. He had undergone left lower lobectomy because of moderately differentiated adenocarcinoma of the left lower lobe in September 1990. Bronchoscopic investigation and three-dimensional reconstruction revealed a tracheal stenotic lesion from recurrent tumor. To relieve the dyspnea and keep the airway, we burned the tumor with endoscopic laser therapy. But 2 weeks later, while systemic investigations were performed for a choice of treatment including surgical resection, the dyspnea recurred, and so after reburning of the tumor we inserted a SENS as described above. Immediate irradiation of the tracheal tumor (40 Gy) and the left supraclavicular lymph nodes (28 Gy) and biochemical modulation therapy (cisplatinum, 22 mg/week, continuous venous infusion, and oral uracil and futrafur [Taiho Pharmaceutical Corp, Tokyo, Japan], 400 mg/day, every day for 5 weeks) were also administered.
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Fig 2. . (A) Chest computed tomogram before placement of the stent shows polypoid tumor (arrowheads) from the left tracheal wall. (B) Three-dimensional reconstruction of the chest computed tomogram before placement of the stent shows polypoid tumor (arrowhead) from the left tracheal wall. (C) Bronchoscopic findings before placement of the stent reveal severe tracheal stenosis (about 90%) by polypoid recurrent tumor (arrowhead = tracheal lumen). (D) Four months after placement of the stent in the trachea, three-dimensional reconstruction of the chest computed tomogram shows the stent in position and fully expanded.
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One year after SENS insertion the patient was alive and well with no dyspnea or discomfort. Bronchoscopic and radiologic investigations revealed satisfying dilatation and no displacement.
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Patient 2
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In November 1995, a 63-year-old man (Fig 3) was referred to our hospital with hemoptysis and dyspnea. He had recurrent tumor in the mediastinal lymph nodes from esophageal cancer, which invaded the trachea. After external irradiation (60 Gy) and brachytherapy (10 Gy x 2 times), the tumor was necrotized, a sinus developed between the trachea and the metastatic lymph node, and tracheal stenosis became worse. Under intravenous sedation, the SENS was inserted as described above after being cut to 8 cm in length. After the insertion his dyspnea was relieved, but after 10 weeks he died of hemoptysis from a necrotic metastatic lymph node.
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Fig 3. . (A) Chest computed tomogram before irradiation shows metastatic lesion (arrowhead) in a paratracheal lymph node. (B) Chest computed tomogram after irradiation shows a sinus (arrowhead) developed between the trachea and the metastatic lymph node. (C) Three-dimensional reconstruction of chest computed tomogram before placement of the stent shows a sinus (arrowhead) between the trachea and the metastatic lymph node. (D) Three-dimensional reconstruction of chest computed tomogram after placement of the stent shows the stent in position and fully expanded.
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Comment
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The SENS is knitted of a 0.15-mm nitinol wire (Elastalloy; Boston Scientific Corp) made of nickel and titanium. This knitted wire is characterized by both high flexibility and great power of restitution. We successfully treated a case of stenosis of the left main bronchus by using the Accuflex Biliary Stent System (Boston Scientific Corp) made from same materials with a 10-mm diameter [7]. The Ultraflex is encased in gelatin, which can be dissolved by drinking warm water after insertion for esophageal use, but it is necessary to dissolve the gelatin before insertion for tracheal use. Fully expanded stents measure 18 mm in diameter, with the proximal end flared into a 5-mm-long collar with a 20-mm diameter, and it is easy to stretch and compress the stent to minimize the diameter at insertion. In both of the present cases a 10-cm-long stent was used; it was cut to 8 cm length for patient 2. The SENS can be cut to the proper length determined after preoperative three-dimensional reconstruction. The knitted wire with shape memory may never get loose, but it is possible to release the stent by pulling the end of the stent. In both cases no tumor proliferated through the meshes. The fine and uniform structure may protect against tumor proliferation through the mesh. After such a short follow-up the tolerance cannot be judged, but because the stent presses the mucosa of the airway at multiple points, the risk of erosion of the stent into adjacent tissues may be decreased.
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Footnotes
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Address reprint requests to Dr Yanagihara, Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University, Shogoin Sakyo-ku, Kyoto, 606, Japan.
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References
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- Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial tree: expandable metallic stents used in experimental and clinical applications. Radiology 1986;158:309–12.[Abstract/Free Full Text]
- Simonds AK, Irving JD, Clarke SW, Dick R. Use of expandable metal stents in the treatment of bronchial obstruction. Thorax 1989;44:680–1.[Abstract/Free Full Text]
- Varela A, Maynar M, Irving D, et al. Use of Gianturco self-expandable stents in the tracheobronchial tree. Ann Thorac Surg 1990;49:806–9.[Abstract]
- Tsang V, Williams AM, Goldstraw P. Sequential Silastic and expandable metal stenting for tracheobroncheal strictures. Ann Thorac Surg 1992;53:856–60.[Abstract]
- Nomori H, Kobayashi R, Kodera K, Morinaga S, Ogawa K. Indications for an expandable metallic stent for tracheobronchial stenosis. Ann Thorac Surg 1993;56:1324–8.[Abstract]
- Cwikiel W, Stridbeck H, Transberg KG, et al. Malignant esophageal strictures: treatment with self-expanding nitinol stent. Radiology 1993;187:661–5.[Abstract/Free Full Text]
- Muro K, Mizuno H, Yanagihara K, Ike O, Wada H, Hitomi S. Self-expanding nitinol stents for treatment of tracheobronchial and esophageal stenosis caused by lung cancer. J Jpn Assoc Thorac Surg 1996;44:2205–11.
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Abstract
Introduction
