Ann Thorac Surg 2001;71:698-699
© 2001 The Society of Thoracic Surgeons
Case report
Inflammatory endobronchial stenosis
Kazuhiro Yanagihara, MD, PhDa,
Katsunari Matsuoka, MDa,
Nobuharu Hanaoka, MDa,
Katsunori Toda, MDa,
Kotaro Muro, MDa
a Department of Thoracic Surgery Kyoto Hakuaikai Hospital, Kyoto, Japan
Accepted for publication February 20, 2000.
Address reprint requests to Dr Yanagihara, Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
e-mail: kazuhiro{at}kuhp.kyoto-u.ac.jp
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Abstract
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We encountered a 71-year-old woman with inoperable bronchial stenosis of the right main bronchus, which was caused by inflammatory granulation infected with Pseudomonas aeruginosa in posttuberculous bronchiectasis. Two months after placement of self-expanding nitinol stents, fiberoptic bronchoscopic examination to investigate hemosputum revealed endobronchial granuloma formation. Endobronchial granulation has disappeared with long-term oral administration of tranilast.
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Introduction
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We have already successfully treated some cases with inoperable stenosis of the airway due to malignant tumors by using a self-expanding nitinol stent (SENS) [1–3]. Various reports have been published about self-expanding metallic stents in benign bronchial stenosis [4, 5].Using a SENS we successfully treated a case with inoperable bronchial stenosis of the right main bronchus caused by inflammatory granulation infected with Pseudomonas aeruginosa in posttuberculous bronchiectasis.
In October 1998, a 71-year-old woman was admitted to Kyoto Hakuaikai Hospital with fever and productive cough. She had undergone right-sided thoracoplasty because of pulmonary tuberculosis about 40 years before. She was given a diagnosis of posttuberculous bronchiectasis and was followed with oral administration of clarithromycin for the last year in our hospital. Intravenous administration of cefepime dihydrochloride once improved her symptoms and normalized serum level of C-reactive protein. However, after 4 days a chest roentgenogram film showed complete atelectasis of the right-sided lung (Fig 1A). Fiberoptic bronchoscopic investigation revealed pinhole-like stenosis of the right main bronchus, 2 mm in diameter (Fig 2A), which was able to be slightly dilated with a balloon after 3 days. Because of insufficient dilation, after 1 week a 20-mm-long SENS (Ultraflex Tracheobronchial Stent System; Boston Scientific, Natick, MA) was inserted using fiberoptic bronchoscopy and fluoroscopic guidance. Immediately after stent placement massive sputum was brought up. The stent was too short to prevent migration and restenosis caused by granulation of this orifice (Fig 2B); consequently, after 5 days a 40-mm-long SENS was reinserted in the same way.
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Fig 1. (A) Chest roentgenogram showing atelectasis of the right-sided lung. (B) Chest roentgenogram showing the right main bronchus dilated with self-expanding nitinol stent.
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Fig 2. (A) Bronchoscopic finding showing the pinhole-like stenotic right main bronchus (arrow). (B) Bronchoscopic finding 5 days after placement of a stent 20 mm long, showing granulation in the orifice of the right main bronchus. (C) Bronchoscopic finding 2 months after stent placement, showing granulation with bleeding around the stent in the right main bronchus. (D) Bronchoscopic finding 8 months after stent placement, showing the right main bronchus dilated with self-expanding nitinol stent and mucosal formation on the stent.
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Two months after stent placement the patient complained of hemosputum. Fiberoptic bronchoscopic examination revealed granulation with bleeding around the stent (Fig 2C). The patient was treated with nebulized inhalations including corticosteroids, as well as orally administered tranilast and clarithromycin.
Eight months after stent placement, in addition to bronchiectasis she complained of intermittent hemoptysis and fever, which were treated with hemostatic agents and antibiotics; however, she is currently alive and well, without restenosis or regranulation (Figs 1B and 2D). At the last follow-up, the orifice of the right main bronchus was 9 mm in the diameter.
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Comment
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The SENS is knitted from a 0.15-mm nitinol wire (Elastalloy, Boston Scientific, Natick, MA) made of nickel and titanium. This knitted wire is characterized by both high flexibility and great power of restitution [2]. Continual self-expanding force works evenly on the wall of the airway because of the fine and uniform structure of the SENS. However, the SENS cannot erode through the airway with overexpansion of its size.
At first we selected a 20-mm-long stent to dilate the stenotic bronchus at as short a distance as possible, but failed. Inadequate stent length caused migration and reactive granulation formation, resulting in restenosis. It is very important to select a stent of the proper length, and preoperative three-dimensional reconstruction is most useful.
The endobronchial surface of the implanted stent is covered by respiratory epithelium, and the stent becomes resistant to migration and improving mucociliary clearance of secretion. In our case the knitted wires were covered by epithelium and endobronchial granulation was formed around the stent. The most common complication is granuloma formation, especially placed in active inflammation [4].
Tranilast, N-(3, 4-dimethoxycinnamoyl) anthranilic acid, has been clinically used for the treatment of the patients either with allergic conditions such as bronchial asthma, allergic rhinitis, and atopic dermatitis, or with proliferative disease such as keloids and hypertrophic scars. It inhibits collagen synthesis in keloid fibroblasts and release of transforming growth factor-ß1 (TGF-ß1) from the fibroblast [6], as well as inhibiting collagen mRNA expression in the fibroblasts elevated with TGF-ß1 [7]. It also modulates the fibrosis and contraction of granulation tissue by inhibiting the growth of myofibroblast-like cells and fibroblasts [8]. Its major adverse effects are liver dysfunction and cystitis-like symptoms. It is generally given at a dose of 300 mg daily for several years. In ongoing clinical trials it is used to prevent restenosis after percutaneous transluminal coronary angioplasty. We consider that tranilast is useful for prevention of endobronchial granulation after stent placement. However, careful long-term follow-up is necessary with regard to the mechanical durability of SENS and the inhibition of granulation with tranilast.
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References
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Abstract
Introduction
