Ann Thorac Surg 2007;83:1897-1899
© 2007 The Society of Thoracic Surgeons
Case Reports
Tracheal Stenting of Iatrogenic Tracheal Injury: A Novel Management Approach
Adam C. Yopp, MD*,
Jeremy G. Eckstein, MD,
Richard H. Savel, MD,
Sunil Abrol, MD
Department of Surgery, Division of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, New York
Accepted for publication December 13, 2006.
* Address correspondence to Dr Yopp, Maimonides Medical Center, 4802 Tenth Ave, Brooklyn, NY 11219 (Email: ayopp{at}hotmail.com).
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Abstract
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We report the case of a patient who had an intubation-related tracheal injury who we treated by deployment of a covered tracheal stent. This approach may be preferable to other alternatives in patients with a prohibitive risk of mortality with surgical repair or in an injury with sequelae not suitable for conservative management.
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Introduction
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Iatrogenic injury to the tracheobronchial tree after intubation is an extremely rare occurrence that historically has been managed either expectantly or with a highly morbid surgical reconstruction. We report of the successful use of a tracheal stent to repair an intubation-associated tracheal injury.
A 75-year-old woman with a history of chronic obstructive pulmonary disease, idiopathic pulmonary hypertension, and severe cervical-thoracic spine scoliosis underwent repair of a humeral head fracture. The procedure was initially done with a scalene nerve block, but owing to ipsilateral phrenic nerve paralysis, the patient went into respiratory distress and required intubation. The intubation was difficult because of aberrant cervical anatomy in the setting of her spinal disease. A fiberoptic bronchoscopic intubation was performed after multiple unsuccessful attempts at intubation via direct laryngoscopy. The intraoperative course was unremarkable, and the patient was extubated without incident in the operating room.
Approximately 2 hours after the conclusion of the procedure, progressively worsening respiratory distress developed. Physical examination revealed minimal subcutaneous emphysema, and a chest roentgenogram revealed no abnormalities. Computed chest tomography revealed a defect of the posterior trachea, approximately 1.5 cm proximal to the carina, as well as widespread pneumomediastinum (Fig 1). Bronchoscopic examination of the trachea confirmed a 4.0 cm tear of the posterior membranous trachea, 1.5 cm proximal to the carina (Fig 2).
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Fig 1. Computed chest tomography reveals a defect in the posterior trachea, 1.5 cm proximal to the carina (white arrow).
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Given the worsening subcutaneous emphysema and increasing respiratory compromise requiring mechanical ventilation, the patient was immediately taken to the operating room. Because of the patient’s severe underlying pulmonary comorbidity, a decision was made to use a tracheal stent to repair the injury rather than a more invasive surgical reconstruction. A 6-cm x 14-mm self-expanding, covered metallic stent (Microinvasive, Natick, MA) was deployed over the tracheal injury and 0.5 cm proximal to the carina under bronchoscopic and fluoroscopic guidance.
The patient was started on broad-spectrum antibiotics and was successfully extubated 2 days later. After an unremarkable further hospital course, the patient was discharged home on postoperative day 5.
The patient underwent monthly flexible bronchoscopic surveillance, which documented only minimal formation of granulation tissue. At 4 months, excess respiratory secretions developed, and flexible bronchoscopy revealed significant granulation tissue at the proximal end of the covered stent. The tracheal stent was removed using rigid forceps through rigid bronchoscopy, with only slight difficulty. The underlying trachea was well healed (Fig 3). During the procedure, ventilation and oxygenation were ensured by high-frequency jet ventilation. The patient was discharged home the next day and remains asymptomatic 1 year later.
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Fig 3. Bronchoscopic view shows the healed posterior tracheal injury after stent was removed (white arrow is previous injury site).
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Comment
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Iatrogenic tracheobronchial tree injuries after intubation occur in less than 0.5% of single-lumen intubations and are associated with well-described anatomic and mechanical factors [1]. Gross overinflation of the tracheal cuff, double-lumen endotracheal intubation, inappropriate endotracheal tube size, operator inexperience, or aberrant tracheal anatomy are the events responsible for most of the injuries.
Clinical evidence of such injuries is usually fairly apparent and often presents immediately upon extubation or within the first 12 hours postprocedure. Symptoms may include subcutaneous or mediastinal emphysema, hemoptysis, or in more severe instances, dyspnea or respiratory compromise, or both. The frequency of pneumothorax is historically quite variable, ranging from 0% to 25% in most series, and its absence does not exclude the presence of an injury [2–4]. Development of these symptoms after intubation or extubation should raise the clinical suspicion of a tracheobronchial tree injury. Prompt tracheobronchoscopy should then be performed to confirm the diagnosis and establish the location and length of injury as a guide to further management decisions.
Iatrogenic tracheobronchial tears have typically been handled conservatively in patients with small tears (<4 cm in length) or those without progressive worsening of their clinical status (eg, respiratory failure or increasing mediastinal or subcutaneous emphysema, or both) [4]. Few early or late complications, including tracheal stenosis or infection, have been documented with this approach, and failure of conservative management in this carefully selected subset of patients is rare.
Large tracheal tears (>4 cm in length) are traditionally managed surgically because they are usually deeper in nature and, in general, fail conservative treatment [4]. The specific surgical approach taken is predicated on the location of tracheal injury: lesions found in the proximal two thirds of the trachea are approached with a cervical collar incision as described by Angelillo-Mackinlay [5], and injuries in the distal one third are managed through a right thoracotomy. The mortality for surgical repair is quite variable, from 0% to 40%, depending on the comorbid condition of the patient [6, 7].
Formal surgical repair of large distal tracheal tears may be prohibited in patients with significant underlying comorbidities. In this population, we believe the deployment of a covered tracheal stent is a viable, effective, and safe alternative. Tracheobronchial stents have long been used in the management of airway obstruction in both malignant and benign disease, with excellent short-term symptomatic relief, but varying long-term problems have occurred [8, 9]. Metallic, expanding, covered tracheal stents are associated with granulation tissue formation, halitosis, stent fracture and migration, and recurrent respiratory infections [8, 9]. Formation of obstructing granulation tissue is the most common complication, with close to one third of stented patients requiring neodymium-doped yttrium aluminium garnet laser ablation of such tissue. Although granulation tissue has been documented as early as 3 weeks after stenting on bronchoscopic surveillance, most instances of symptomatic granulation tissue occur after long-standing stent deployment [8].
Evidence of symptomatic granulation tissue formation developed in our patient at 4 months, and we believe that the use of stents for tracheal tears requires close bronchoscopic tracheal surveillance and stent removal at the first signs of excess granulation tissue. Historically, covered metallic stents have been promulgated as permanent and difficult to remove, but recently published reports demonstrate that newer second-generation metallic stents (as used in this patient) can be safely and successfully removed with little or no difficulty by an experienced endoscopist [10]. The use of silicone stents in place of covered metallic stents for treating tracheal tears may eliminate the complications caused by excess granulation tissue formation—seen in 3% to 10% of silicone stents for obstructive airway disease—and subsequent bronchoscopic interventions [11, 12]. Unfortunately, high rates of stent migration (seen in approximately one third of deployments for benign airway disease) may limit their effectiveness in the treatment of tracheal tears [11, 12].
We believe this use of the tracheal stent is a useful therapy in a large tracheal injury or if the patient’s progressive respiratory manifestations do not allow for conservative therapy. We also believe tracheal stenting is a valid alternative in patients where the overall condition of the patient precludes formal surgical reconstruction, given the relatively high rate of perioperative morbidity and mortality. We present our proposed treatment algorithm for the management of postintubation tracheobronchial injuries in Figure 4.
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References
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Abstract
Introduction
