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Ann Thorac Surg 2000;70:1191-1193
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation

^a Department of Cardiothoracic Surgery, St George’s Hospital, London, England, UK
^b Department of Cardiological Science, St George’s Hospital, London, England, UK

Address reprint requests to Dr Madden, Department of Cardiothoracic Surgery, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, England

	Abstract

Top Abstract Introduction Patients and methods Comment References

 
Background. Tracheal obstruction secondary to benign proliferation of granulation tissue is a difficult problem to address if tracheal resection is contraindicated. Some patients may benefit from Nd:YAG (neodymium:yttritium-aluminum garnet) laser fulguration or tracheal stenting. If uncovered expandable metallic stents are employed granulation tissue can regrow and proliferate through the mesh, thereby obstructing the lumen once again. Covered metallic stents confer the advantage of preventing granulation tissue proliferation and therefore maintain patency of the tracheal lumen.

Methods. Two patients who developed tracheal obstruction secondary to proliferating granulation tissue formation after tracheostomy and who were medically unfit for prolonged general anesthesia were successfully treated using covered expandable metallic tracheal stents.

Results. Each patient demonstrated a significant improvement in respiratory status, and in both patients, at 6 and 9 months’ follow-up, stent position has not changed, tracheal lumen remains patent, and there has been no proliferation of granulation tissue through the stent.

Conclusions. Covered expandable metallic stents should be considered in the management of patients with proliferating tracheal granulation tissue when tracheal resection is contraindicated.

	Introduction

Top Abstract Introduction Patients and methods Comment References

 
Expandable metal stents have been successfully applied to the management of extrinsic and intrinsic narrowing of the trachea and bronchi. However, uncovered metallic stents may permit the growth of endobronchial tumor or granulation tissue through the wire in the stent. Therefore, covered stents offer theoretical advantages in treating patients with proliferating endotracheal

and endobronchial tumors and granulation tissue. We describe the successful use of covered expandable metallic stents, placed bronchoscopically under direct vision, in two patients who developed tracheal stenosis due to benign granulation tissue formation after tracheostomy.

	Patients and methods

Top Abstract Introduction Patients and methods Comment References

 
Patient 1
A 33-year-old Afro-Caribbean woman was mechanically ventilated for 43 days through a tracheostomy after an episode of Pneumocystis carinii pneumonia 1 year after seroconverting with human immunodeficiency virus. She was being treated with quadruple antiviral therapy for cerebral HIV infection and had a history of cerebrovascular accident and severe keloid formation. After successful treatment of her pneumonia, she was readmitted to hospital with stridor 3 months later. At fiberoptic bronchoscopy, circumferential granulation tissue was found 5 cm below the vocal cords, reducing the tracheal luminal diameter to 4 mm. Biopsy of the tissue confirmed benign granulation tissue. She had a rigid bronchoscopy with Nd:YAG (neodymium:yttritium-aluminum garnet) laser therapy, which increased the luminal diameter to 6 mm. The granulation tissue recurred in spite of repeat rigid bronchoscopy with laser fulguration and bougie treatment. She also had three episodes of Staphylococcus aureus respiratory infection, which were successfully treated with flucloxacillin on each occasion.

She was considered unsuitable for tracheal resection and reconstruction because of concern over granulation tissue formation at the site of the tracheal anastomosis and also because of her poor pulmonary reserve as a consequence of previous Pneumocystis carinii pneumonia and pulmonary fibrosis. Because of her keloid background and the nature of the granulation tissue, there was concern that it would proliferate through an uncovered expandable metal stent. We therefore believed that a covered stent would be more appropriate.

A covered expandable metallic stent composed of a titanium mesh and a polyvinyl chloride covering was manufactured (Microinvasive, Boston Scientific, Watertown, MA). It was placed in an unexpanded state under direct vision at rigid bronchoscopy and, by pulling a nylon drawstring, it was expanded to its maximum size (length = 60 mm, outer diameter = 18 mm). After this treatment the patient’s peak expiratory flow rate measurement increased significantly (from 80 to 359 L/s) and she was discharged home. Check bronchoscopy 1 month later revealed granulation tissue just beyond the distal end of the sent. The tissue was treated with Nd:YAG laser fulguration and has not recurred. At 9 months’ follow-up the patient was working full-time, sputum culture was negative for pathogenic organisms, and she had no stridor or dyspnea. Chest radiography (Fig 1) and bronchoscopy confirmed correct positioning of the stent.

View larger version (160K): [in this window] [in a new window]   Fig 1. Chest roentgenogram from patient 1, showing satisfactory stent position 9 months after insertion.

A covered expandable tracheal stent (Microinvasive, Boston Scientific) was placed under direct vision at rigid bronchoscopy (expanded length = 60 mm, outer diameter = 18 mm). Nebulized hypertonic saline was prescribed postinsertion to humidify and facilitate sputum expectoration. She developed a methicillin-resistant Staphylococcus aureus respiratory infection, which was successfully treated with intravenous antibiotics, and she was discharged to her local hospital for continuing rehabilitation care. At 6 months’ follow-up she has no stridor and her respiratory function has improved.

	Comment

Top Abstract Introduction Patients and methods Comment References

 
Tracheal resection and reconstruction operations [1, 2] are the gold standard for tracheal stenoses caused by benign granulation tissue. Some patients may be medically unfit for these procedures and alternative approaches such as Nd:YAG laser fulguration or tracheal stenting are employed.

The first commonly employed tracheal stent, the Montgomery T tube [3], described in 1974, was made of silicone and necessitated a tracheostomy for its use. It often became blocked by dried secretions due to lack of humidification. Subsequently, silicone tracheal tubular stents [4–6] have been placed without tracheostomy but the disadvantages of silicone include a tendency to interfere with normal mucociliary clearance and to block bronchial orifices, resulting in atelectasis and pneumonia. They can also become displaced. Wallace [7] experimented with the use of expandable metallic mesh tracheobronchial stents, concluding that they overcame these problems and did not cause tracheitis. In addition, stent migration was less frequent. Further studies [8–10] have validated the use of expandable metallic stents in diverse pathologies such as tracheobronchial stenosis (because of malignancy or tracheostomy), tracheoesophageal fistula, and tracheobronchial malacia after lung transplantation. These stents can be used as an adjunct to other therapies, including laser resection, electrocoagulation, and cryocoagulation, and offer a viable alternative to surgical reconstruction of the trachea.

However, in patients with a fibroinflammatory etiology of their tracheobronchial stenoses, continued inflammation renders the expandable noncovered metallic stent less effective. Indeed, a common complication of these stents in large airways is granulation tissue proliferation through the stent [11]. This can be a difficult problem to address, particularly as subsequent stent removal is frequently impossible. One article describes the use of a covered expandable tracheal stent in a terminally ill patient with local invasion of bronchogenic carcinoma into the trachea [12].

We describe the successful application of polyvinyl chloride-covered expandable titanium metal mesh stents in two patients who had extensive granulation tissue that had resulted in severe tracheal stenosis. Whereas metallic stents can relieve stenoses caused by extrinsic compression, most commonly due to malignancy, the covered expandable stents were especially manufactured and employed in our two patients to address intrinsic obstruction caused by proliferating granulation tissue. We were concerned that such tissue would grow through an uncovered stent. Although Nd:YAG laser could theoretically be applied to granulation tissue that grew through the mesh of the stent, we believed that a covered stent would be a more appropriate option. We appreciate that, like silicone stents, covered expandable metallic stents have the potential disadvantage of impeding mucociliary clearance and thereby preventing sputum retention. This, however, was not a problem in either patient described. We inserted the stents under general anesthesia using rigid bronchoscopy because each patient had significant upper airway obstruction and poor respiratory reserve. We wished to maintain control of the airway at all times during the procedure. It was our belief that insertion of stents in these two patients under local anesthesia using fiberoptic bronchoscopy would have carried a significant risk to each patient. Furthermore, we wished to deploy the stents under direct vision, using fiberoptic bronchoscopy to confirm adequate stent position. The use of rigid bronchoscopy also afforded the opportunity of adjusting the position of the stent in the trachea easily if necessary.

In both patients we have successfully used covered expandable metallic stents for tracheal stenoses caused by excessive granulation tissue subsequent to tracheostomy. The covered stent takes expandable metallic stents one step further and offers an improvement on the already tried and tested stents on the market today. The structure of the stent specifically stops granulation or neoplastic tissue from proliferating through the mesh. Moreover, the stent can be placed under direct vision as well as fluoroscopically. In addition, it is in place before expansion is brought about by pulling a nylon thread. In comparison, the majority of previous expandable metallic stents have been placed by pushing them out of a sheath with an obturator, thus occasionally siting them incorrectly and sometimes necessitating the use of more than one stent. Our encouraging early experience with covered expandable metallic stents leads us to suggest that these stents should be considered in the management of patients with tracheal obstruction secondary to granulation tissue formation. [13,14]

	References

Top Abstract Introduction Patients and methods Comment References

 

1. Grillo H.C. Surgical treatment of post-intubation tracheal injuries. J Thorac Cardiovasc Surg 1979;70:860-875.
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Madden, B. P. Articles by Mitchell, P. Search for Related Content PubMed PubMed Citation Articles by Madden, B. P. Articles by Mitchell, P.