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Ann Thorac Surg 2005;79:1054-1056
© 2005 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Gil Heart Center, Gachon Medical School, Inchon, South Korea
Accepted for publication September 10, 2003.
* Address reprint requests to Dr Park, Department of Cardiothoracic Surgery, Gil Heart Center, 1198 Kuwol-dong, Namdong-ku, Inchon 405-220, South Korea
kookyang{at}ghil.com
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Abstract |
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Introduction |
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The current management of ischemic stenosis has included endoscopic debridement (manual fulguration or laser vaporization), balloon dilatation, stenting, and a combination of these approaches with variable success rates [1]. Among the various methods for relieving the obstruction, stenting has been found to be most useful both in benign and malignant lesions. Although most experience has been with silicone rubber stents [2], expandable metal stents have recently been used for various stenotic lesions of the trachea other than the coronary artery [3, 4].
In this case, the initial stent placement was unsatisfactory with a protrusion of distal end on bronchoscopy, which resulted in a catastrophic consequence 1 year later.
An 11-year-old girl with complex congenital heart disease underwent heart lung transplantation on April 20, 1997. Her preoperative diagnosis was pulmonary atresia with an intact ventricular septum, right ven-tricle dependent coronary circulation, and multiple major aortopulmonary collaterals with pulmonary hypertension.
The donor was a 9-year-old traffic accident victim who had the same blood type. The heart-lung block was placed in the chest anterior to the phrenic nerve [5]. Tracheal anastomosis was completed with a single 4-0 Prolene suture (Ethicon Inc, Sommerville, NJ) in a continuous over-and-over method. The anastomosis was reinforced by pericardial flap wrapping. The graft ischemic time was 120 minutes. She received the initial immunosuppressive agents with cyclosporine, azathioprine, an intravenous steroid for 2 days, and a 3-day rabbit antithymocyte globulin. Oral steroids were withheld for 2 weeks after surgery.
Her postoperative course was uneventful until week 5, when she began to experience shortness of breath. Computed tomographic scan and bronchoscopy showed that the tracheal diameter had narrowed to 4 mm at the anastomosis site with a deviation to the left. During the next several weeks laser ablations of the granulation tissue were performed under rigid bronchoscopy with some symptomatic improvement for 4 weeks. However her respiratory distress worsened. In order to provide long-term relief of her dyspnea, it was decided to place a stent. She was brought to the cardiac catheterization room, sedated, and intubated. The stenotic segment was first dilated by a balloon (6 to 12 mm size) (Ultrathin balloon [Mansfield Co, Boston, MA]) with a pressure of 10 to 14 atm. A Palmaz stent (8 mm x 30 mm) (Johnson & Johnson Interventional Systems Co) was then delivered into the dilated lesion and inflated with a high pressure. The stent size (8 mm) was chosen considering the narrowest dimension (4 mm) of the anastomosis site. The position of the stent and the adequacy of inflation was checked by fluoroscopy (Fig 1) and bronchoscopy (Fig 2), which showed a solid contact of the stent with the tracheal mucosa at its upper part. However, the lower part was free floating to the middle of the airway, which seemed to be caused by the small stent size and also by a deviation of the trachea to the left. (Fig 1D) After the procedure, the patient's shortness of breath disappeared, and she was extubated on the same day. One month later, repeat ballooning was attempted to further increase the stent dimension in order to fix the lower stent end to the tracheal wall, but with limited success. The removal of the older stent and placement of a new stent were considered too risky.
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If the lesion is relatively fixed by the fibrotic changes, effective therapy will often require stenting with a dilation and debridement of the airway to achieve long-term relief [1]. Most experience has been with silicone rubber stents for a variety of tracheobronchial obstructions [2, 3]. However, early trials with silicone rubber stents have shown frustrating results with migration, narrowing of the lumen, and interference of the mucociliary function [1].
Self-expandable metallic stents, such as Gianturco stents (Cook Inc, Bloomington, IN) [1, 5, 7], have been developed and used for various lesions including a vascular stenosis. These stents provide effective relief of an airway obstruction. They are well tolerated, and allow normal clearance of the secretions with improved mucociliary clearance as the metallic mesh becomes overgrown with the respiratory epithelium.
The balloon expandable Palmaz stent (Johnson and Johnson Interventional Systems Co) is made of stainless steel in the form of a tubular mesh and has been designed primarily for vascular stenosis [5]. More recently the indication has expanded toward benign and malignant tracheobronchial stenotic lesions. The Palmaz stent requires a balloon to expand it. These stents are available in many internal diameters and lengths. Before expansion, the proper choice of length and maximum diameter of the stent is critical as it is practically impossible to remove or reposition after it is deployed.
In our case, ballooning and laser ablation were attempted before stenting, but long-term relief could not be achieved. The immediate relief of the patient's symptoms was followed by recurrence of respiratory distress several weeks later. The free floating of the distal end of the stent was partly caused by a deviation of the stenotic trachea to the left side, but also by the smaller stent size. It was also pointed out that the distal tip of the stent went too deep from the narrowest point (Fig 1 D) This distal stent floating was believed to be a nidus of the Candida albicans infection that appeared later.
We still believe that the expandable metallic stent is preferable to other types of stents in treating tracheal stenosis. However, the proper selection of size and position of the stent should always be considered as of utmost importance [8, 9]. If an oversized stent had been used and the proper position been selected, the distal free floating problem could have been avoided regardless of the deviation of the stenotic trachea. We believe that this is the first case of Candida infection of the tracheal stent after heart-lung transplantation.
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This article has been cited by other articles:
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  J. F. Santacruz and A. C. Mehta Airway Complications and Management after Lung Transplantation: Ischemia, Dehiscence, and Stenosis Proceedings of the ATS, January 15, 2009; 6(1): 79 - 93. [Abstract] [Full Text] [PDF]
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