Ann Thorac Surg 2000;70:1389-1390
© 2000 The Society of Thoracic Surgeons
Case report
Simple technique for sizing and positioning tracheal stents
Jemi Olak, MDa,
Stefanie Rosenberg, MS, PACa
a Department of Thoracic Surgery, Lutheran General Hospital, Park Ridge, Illinois, USA
Address reprint requests to Dr Olak, Lutheran General Hospital, Cancer Care Center, 1700 Luther Ln, Park Ridge, IL 60068
e-mail: jemi.olak{at}advocatemedical.com
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Abstract
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Accurate placement of tracheobronchial stents is essential, since little adjustment can be made once the stent is deployed. We describe the use of an inexpensive tool, a radio-opaque ruler, to aid in the proper positioning of tracheobronchial stents.
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Introduction
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Tracheal obstructions from either intrinsic or extrinsic causes may cause debilitating cough and life-threatening dyspnea (Fig 1). Surgical resection is usually not advocated and therapeutic options are limited [1]. Palliation of the symptoms caused by extrinsic compression of the tracheobronchial tree can be accomplished with placement of a covered or noncovered self-expanding stent. Once placed, however, stent repositioning or removal is quite difficult or impossible, mandating accurate first-time placement. The following technique was performed on a 51-year-old male patient with small cell lung cancer invading the mediastinum. The mass was causing extrinsic compression of the trachea and significant respiratory distress.
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Fig 1. Chest radiograph with arrows indicating the area of maximum extrinsic compression of the upper one-half of the trachea by metastatic small cell lung cancer.
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After induction of general anesthesia and with the patient supine, a 6-mm rigid bronchoscope (Pilling, Fort Washington, PA) was advanced through the vocal cords. A moistened 6-inch roll of packing gauze was placed in the oropharynx to minimize retrograde airleak around the bronchoscope. The distance from the vocal cords to the proximal point of obstruction was noted. The bronchoscope was then advanced beyond the point of obstruction. A radio-opaque ruler (Vascutech, Burlington, MA), was taped to the right anterior chest wall lateral to the trachea. The bronchoscope was withdrawn under fluoroscopic guidance, and the distal and proximal extents of tracheal compression were mapped out on the ruler. For the patient shown in Figure 1, it was determined that the distal and proximal extent of compression corresponded to the 8-mm and 20-mm marks on the ruler (Fig 2). The trachea was dilated by sequentially replacing the 6-mm rigid bronchoscope with a 7-mm scope, and then an 8-mm scope. After viewing the diameter of the distal trachea beyond the obstruction, a 14-mm x 6-cm tracheal stent (Microvasive, Natick, MA) was selected to span the obstruction and, at the same time, remain below the level of the vocal cords. A guidewire was passed through the rigid bronchoscope, and its tip positioned in the right mainstem bronchus under fluoroscopic guidance. The rigid bronchoscope was then withdrawn, the 14-mm x 6-cm tracheal stent was advanced over the guidewire, and the proximal and distal radio-opaque markers on the stent were aligned with the 20-mm and 80-mm marks on the ruler. The stent was deployed under fluoroscopic guidance making sure that the inferior and superior stent markers remained properly aligned with the marks on the ruler. The rigid bronchoscope was withdrawn to a position immediately below the vocal cords while a flexible bronchoscope (Olympus, Lombard, IL) was passed through the rigid bronchoscope and confirmed that the tracheal stent was positioned across the area of extrinsic compression. A confirmatory chest radiograph (Fig 3) was completed. The patient was lightened from anesthesia and the bronchoscopes were removed.
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Fig 2. Intraoperative fluoroscopy demonstrates that the tracheal stent has been deployed across the area of obstruction between the 80-mm and 20-mm marks on the radio-opaque ruler.
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Fig 3. Postoperative chest radiograph with arrowsdemonstrating the same area expanded by the tracheal stent.
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Comment
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Successful palliation of tracheal stenoses requires accurate placement and sizing of tracheal stents. Accurate stent size assessment and placement helps significantly to decrease the problem of stent migration [2]. The use of a radio-opaque ruler makes placement of tracheal stents simpler by providing an accurate reference on the patient’s chest wall against which the area of obstruction can be measured, and the stent aligned prior to deployment. Accurate initial placement of the self-expanding stent is critical, since, once deployed, only a few millimeters of superior displacement of the stent can be safely tolerated.
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References
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Carrasco C.H., Nesbitt J.C., Charnsangavej C., et al. Management of tracheal and bronchial stenoses with the Gianturco stent. Ann Thorac Surg 1994;58:1012-1017.[Abstract]
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DeSouza A.C., Keal R., Hudson N.M., Leverment J.N., Spyt T.J. Use of expandable wire stents for malignant airway obstruction. Ann Thorac Surg 1994;57:1573-1578.[Abstract]
Accepted for publication January 22, 2000.
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[Abstract]
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Abstract
Introduction
