Ann Thorac Surg 2003;76:597-598
© 2003 The Society of Thoracic Surgeons
Case report
Saber-sheath malacic trachea remodeled and fixed into a normal shape by long-term placement and then removal of gianturco wire stent
Ichiro Fukai, MDa*,
Yosuke Yamakawa, MDa,
Masanobu Kiriyama, MDa,
Masahiro Kaji, MDa,
Motoki Yano, MDa,
Hidefumi Sasaki, MDa,
Yoshitaka Fujii, MDa
a The Second Department of Surgery, Nagoya City University Medical School, Nagoya, Japan
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Fukai, The Second Department of Surgery, Nagoya City University Medical School, Mizuhoku, Nagoya 467-8601, Japan
e-mail: ifukai{at}med.nagoya-cu.ac.jp
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Abstract
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We report the case of a 59-year-old man who presented with major dyspnea due to saber-sheath malacic trachea associated with chronic pulmonary obstructive disease. The placement of a temporary tracheal stent alleviated his dyspnea very well; hence the stent was replaced with a Gianturco wire stent (Cook Cardiology, Bloomington, IN). However, this required removal due to wire-stent-related complications 2 years after the replacement. Surprisingly the trachea had been remodeled to a normal shape resulting in comfortable, functional respiratory status. A review of the literature reveals our case to be the first report of curing saber-sheath malacic trachea without leaving any prostheses or other foreign materials.
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Introduction
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A saber-sheath trachea is a deformity often associated with chronic pulmonary obstructive disease. Some patients with this disease have been treated by external tracheal fixation with foreign materials by thoracotomy [1]. However there is no established therapy for this disease, nor a clear indication for selection thereof. Wire stents have been used to treat malacic trachea despite the risk of airway mucosal injuries [2]. We report a case of saber-sheath malacic trachea in which a Gianturco wire stent (Cook Cardiology, Bloomington, IN) was placed for 2 years. The physical characteristics of the trachea were transformed to be normal after removal of the stent, resulting in comfortable breathing.
A 59-year-old man was transferred to our hospital because of major dyspnea and wheezing from a chronic pulmonary obstructive disease-associated saber-sheath malacic trachea (Fig 1).
We placed a removable internal stent (Dumon stent tube [Bryan, Woburn, MA]), to see if preventing tracheal collapse relieved the obstructive component of the disease. The patient quickly progressed to active physical activity, which had not been possible before placement of the Dumon stent tube (Bryan). However, the presence of the Dumon stent tube (Bryan) resulted in reduced mucociliary clearance [3], and the patient had recurrent pneumonia develop 6 months later, which disappeared after replacement with a Gianturco wire stent (Cook Cardiology). However, the patient described brief episodes of minor stridor 6 months after placement of the Gianturco wire stent (Cook Cardiology). Bronchoscopy revealed prominent ingrowth of granulation tissue into the stent, which was somewhat suppressed by regular steroid inhalation. The patient demonstrated no persistent, obstructive pulmonary symptoms. Eighteen months later, he described coughing up a fragment of wire. A bronchoscopy performed at readmission at 18 months showed prominent granulation ingrowth and disruption of the tracheal wire stent (Fig 2).
A computed tomographic scan showed tracheal wall thickening, suggesting extramural migration by several broken wire fragments.
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Fig 1. Saber-sheath malacic trachea. (A) Bronchoscopy at admission demonstrates saber-sheath trachea deformity. (B) The trachea collapses almost completely during cough.
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Fig 2. Bronchoscopy at 18-month readmission shows prominent granulation ingrowth and disruption of the tracheal wire stent.
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The patient underwent thoracotomy and a 5-cm longitudinal tracheotomy through the membranous portion to remove the stent. A thickened section of the tracheal wall (1 cm in width) was replaced almost entirely by granulation. After complete removal of the wire fragments, a Freitag Dynamic stent (Karl Storz, Tuttlingen, Germany) was placed in the trachea to prevent possible tracheal collapse during exhalation. A computed tomographic scan performed 1 month after the operation demonstrated substantial tracheal enlargement, so we attempted to replace the stent with a larger one. Surprisingly a bronchoscopy performed just after the removal of the stent, revealed that the trachea was normal in shape and showed no saber sheathing during coughing (Fig 3).
Therefore we decided not to place the new stent. The patient was discharged 2 weeks later, breathing more easily than at any time after the placement of the Gianturco wire stent (Cook Cardiology). He has reported his respiratory status as being acceptable for the past 18 months.
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Fig 3. Remodeled trachea. (A) Bronchoscopy at 7 months after removal of the wire stent, which demonstrates remodeled trachea. (B) The trachea no longer collapses during coughing.
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Comment
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A saber-sheath trachea is associated with chronic pulmonary obstructive disease; consequently any procedures preventing tracheal collapse do not correct the underlying small-airway disease [2]. This fact has made it difficult to clearly define the indications for tracheal fixation. However there are undoubtedly patients who would benefit from the tracheal fixation, because it does improve the delivery of gases through the trachea and it does allows a more effective cough. The indication for selection depends on the portion of the obstructive component of the disease that would be relieved by tracheal fixation. Hence, we believe that the temporary placement of a stent is one of the most practical tests for this selection. Evaluation before and after temporary stent placement (including spirometry [changes in forced expiratory volume], diffusion [resting arterial oxygenation], and dyspnea [base line dyspnea index]) would better delineate the indications for tracheal fixation.
The morphologic and functional correction of a saber-sheath malacic trachea lasting 18 months after removal of the wire stent is of great interest. Because the tracheotomy was performed through the membranous portion, it is unlikely that it contributed to the correction of the saber-sheath malacic trachea. Wire stents are known to cause prominent granulation ingrowth and thickening of the tracheal wall within 6 months of placement [4]. We believe that these drawbacks of wire stents, causing local chronic inflammation, served to remodel the saber-sheath malacic trachea. Previous reports indicated successful removal of fractured tracheal wire stents by using rigid bronchoscopy [2, 5].We could have used rigid bronchoscopy to reduce the patient’s burden. On the basis of this experience, one may believe it appropriate to place wire stents in these patients with a plan to remove them in some point by using rigid bronchoscopy. However, fractured wire stents may cause erosion of the trachea and neighboring mediastinal structures [4]. We believe the risk of wire stents outweigh the possible benefits. A sophisticated stent that causes chronic inflammatory stimulus and can be removed safely would overcome this dilemma. A review of the literature reveals our case to be the first report demonstrating the possibility of curing a saber-sheath malacic trachea without leaving any prostheses or foreign materials.
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References
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- Rainer W.G., Feiler E.M., Kelble D.L. Surgical technique of major airway for pulmonary emphysema. Am J Surg 1965;110:786-789.[Medline]
- Hramiec J.E., Haasler G.B. Tracheal wire stent complcations in malacia: implications of position and design. Ann Thorac Surg 1997;63:209-212.[Abstract/Free Full Text]
- Gaissert H.A., Patterson G.A. Tracheobronchial stents. In: Pearson F.G., Deslauriers J., Ginsberg R.J., et al. , eds. Thoracic surgery. New York: Churchill Livingstone, 1995:223-233.
- Rousseau H., Dahan M., Lauque D., et al. Self-expandable prostheses in the tracheobronchial tree. Radiology 1993;188:199-203.[Abstract/Free Full Text]
- Nashef S.A., Dromer C., Velly J.F., Labrousse L., Couraud L. Expanding wire stents in benign tracheobronchial disease: indications and complications. Ann Thorac Surg 1992;54:937-940.[Abstract]
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Abstract
Introduction
