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Ann Thorac Surg 2001;71:1335-1336
© 2001 The Society of Thoracic Surgeons
a Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
b Department of Diagnostic Radiology, Singapore General Hospital, Singapore
Accepted for publication September 22, 2000.
Address reprint requests to Dr Lo, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Rd, Singapore 169608
e-mail: conslo{at}yahoo.com
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Abstract |
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Introduction |
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A 50-year-old man with a 60-pack-year smoking history was transferred to our institution for interventional bronchoscopy to palliate malignant airway stenosis. The obstruction had been confirmed at another hospital by chest radiographs and computed tomograms that showed central airway compression secondary to mediastinal adenopathy. The histology, obtained by mediastinoscopy, was poorly differentiated adenocarcinoma, likely from a lung primary.
Flexible fiber-optic bronchoscopy confirmed extrinsic compression involving the distal 30 mm of the trachea and the proximal 10 mm of the right mainstem bronchus, leaving residual patencies of 6 mm and 6 mm, respectively. The left main bronchus was stenotic to a pinhole diameter. In the ward, acute type II respiratory failure developed, necessitating endotracheal intubation. To relieve the airway obstruction, a 14 x 40-mm silicone stent (Endoxane, Cometh Laboratoire, France) was inserted using rigid bronchoscopy into the distal trachea. The left main bronchus was severely stenotic and indurated, and attempts at dilation resulted in active bleeding. Hence, we were unable to stent the left main bronchus. Despite stent placement into the distal trachea, his dyspnea was unrelieved, and worsening respiratory distress resulted in a second endotracheal intubation, 4 days later.
Subsequently, we attempted to reestablish airway patency at the carina using two overlapping metallic stents, which was done through a rigid bronchoscope under fluoroscopic guidance. The silicone stent in the distal trachea was removed, and a guide wire was threaded into the left main bronchus. Balloon dilation was done with an 8-mm balloon. A 16 x 56-mm uncovered Wall stent (Schneider, Zurich, Switzerland) was deployed from the left lower lobe bronchus into the distal trachea. Using a balloon catheter over a guide wire, a hole was widened in the wire mesh overlying the right main bronchus, allowing for a second overlapping Wall stent (16 x 37 mm) to be deployed within the right main bronchus to the trachea. The wire mesh of the second Wall stent overlying the left main bronchus was dilated with a balloon catheter, creating another hole over the left bronchial orifice. Effective restoration of patency at the distal trachea and right and left main bronchi was achieved with final luminal diameters of 16 mm, 12 mm, and 12 mm, respectively (Figs 1 and 2). The 2-hour-long procedure was complicated by profound intraoperative hypotension, with systolic blood pressure remaining below 90 mm Hg for 1 hour during the procedure. This was believed to be a result of dynamic hyperinflation. Fortunately, no significant clinical sequelae followed the hypotensive event, and the patient was extubated successfully the following day.
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Restoring airway patency for stenoses involving the carina is especially challenging. Successes have been reported with a variety of airway stents, including the T-Y tube, wire-reinforced Y tracheostomal tube, Freitag dynamic airway stent, Hood stents, Y stents, and covered metallic stents [3–5]. Although overlapping Wall stents have been used to stent recurrent disease at the margins of earlier stents [6], in this case, overlapping Wall stents were used primarily to overcome carinal stenosis.
Our decision to use this unconventional method of stenting was determined by several factors, including stent availability in our institution during this crucial period. Although we initially attempted silicone stent insertion, the situation was far from ideal. The carinal stenosis was of mainly extraluminal origin, and the stenosis at the origin of the left main bronchus was tight and hemorrhagic. This precluded adequate prestenting dilation, which is a necessary prerequisite for silicone stent insertion.
In contrast, the Wall stent had numerous features that we considered to be invaluable assets in this case, including radial expansion upon retraction of a cover sheath, which reduces the need for predeployment dilation; excellent radial strength against external compression; small wall-to-lumen ratio, which not only maximizes the diameter of the reopened bronchus, but also allows coaxial placement of a second stent within the first; the ability to cut small windows in the mesh without disrupting the integrity of the stent; and the presence of patent interstices, allowing ventilation to be maintained across nonstenosed bronchi (in our case, the right upper lobe bronchus) [7].
Technical issues aside, a second challenge we faced was in airway management while stenting with general anesthesia. Worsening of underlying airway obstruction, with catastrophic outcomes in some cases, has been reported in all phases and using all forms of anesthesia, whether inhaled or intravenous [8–10]. This was of particular relevance in our case, as we encountered bronchoscopic evidence of worsening airway obstruction after induction. To overcome the ventilatory difficulties, administration of intermittent assisted manual ventilation over the patient’s spontaneous breaths became necessary. The combination of positive pressure ventilation and expiratory airflow limitation from airway obstruction led to dynamic hyperinflation, and profound intraoperative hypotension. Dynamic hyperinflation results in increased intrathoracic pressure, decreased venous return, and increased right ventricular afterload, eventually culminating in cardiac arrest [9, 11]. Furthermore, ineffective ventilation results in respiratory acidosis, leading to hypotension resulting from the myocardial suppressive effects of pH and hypoxia. It is noteworthy that the hemodynamic and airway difficulties resolved completely, with restoration of carinal patency and reversal from anesthesia.
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This article has been cited by other articles:
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  C. Chen and S. Jiang A Novel Anatomy-Conforming Metallic Stent for Tracheobronchial Stenosis Ann. Thorac. Surg., June 1, 2008; 85(6): 2100 - 2103. [Abstract] [Full Text] [PDF]
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 W. Lunn, D. Feller-Kopman, M. Wahidi, S. Ashiku, R. Thurer, and A. Ernst Endoscopic Removal of Metallic Airway Stents Chest, June 1, 2005; 127(6): 2106 - 2112. [Abstract] [Full Text] [PDF]
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