Ann Thorac Surg 2007;84:1758-1760. doi:10.1016/j.athoracsur.2007.03.092
© 2007 The Society of Thoracic Surgeons
Case Reports
Rare and Fatal Complication of Gianturco Tracheobronchial Stent
Sanjay Asopa, MRCSa,
Narain Moorjani, MRCSa,
Rasheed A. Saad, MRCSa,
Jonathan T. Turner, FRCPb,
Khalid M. Amer, FRCS (CTh)a,*
a Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton, United Kingdom
b Thoracic Medical Centre, Royal Bournemouth Hospital, Bournemouth, United Kingdom
Accepted for publication March 26, 2007.
* Address correspondence to Dr Amer, Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom (Email: khalid.amer{at}btinternet.com).
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Abstract
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Tracheobronchial stents are increasingly being used for the management of compromised large airways. Traditionally they have been used to palliate malignant conditions; however, they are now being used more frequently for nonmalignant conditions. The use of Gianturco self-expanding metal stent (William Cook, Bjaeverskov, Denmark) has been challenged for treatment of tracheobroncheomalacia, as fracture of the metal work could prove fatal. In this report we describe a case of fracture in the metal framework of a Gianturco stent resulting in recurrent pneumothoraces; heralding fatal haemoptysis as a result of perforation of the left subclavian artery.
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Introduction
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Tracheobronchial stents are efficacious in relieving critical airway narrowing that causes respiratory distress and life-threatening stridor. Traditionally, large airway stenting is considered a palliative procedure for inoperable malignant conditions. As life expectancy in this cohort of patients is short (ie, 142 days reported by Stockton and colleagues [1]), long-term follow-up results are not available.
Large airway stenting is blighted by stent migration, in-stent obstruction, halitosis, recurrent respiratory infections, and metal framework fracture leading to airway or vascular perforation [2–4]. There are potential advantages in using metallic, noncovered stents for benign stenosis. These include greater ease of placement, greater cross-sectional airway diameter due to thinner wall construction, smaller migration rate, and epithelialization within the stent allowing for maintenance of mucociliary clearance [2, 3].
In this report we describe a case of a Gianturco self-expanding metal stent (William Cook, Bjaeverskov, Denmark) fracture and perforation of the tracheal wall, leading to recurrent right pneumothoraces and fatal haemoptysis due to perforation of the left subclavian artery.
A 64-year-old woman with relapsing polychondritis presented with worsening stridor due to tracheobronchomalacia. She had a protracted history of chest infections requiring at least one admission to intensive care for mechanical ventilation. She was treated with immunosuppressive therapy (ie, methylprednisolone and azathioprine) in an attempt to arrest further deterioration of her condition. The patient was also diagnosed with a multinodular goiter, which was believed to be compressing the trachea and contributing to her stridor. Her symptoms failed to improve after a partial thyroidectomy. A helical computed high-resolution tomographic scan of the trachea and chest demonstrated a 6-mm diameter trachea at the level of the aorta. Both major bronchi were narrowed to 6 to 7 mm and collapsing to 2 to 3 mm on expiration, representing dynamic tracheal stenosis.
Rigid bronchoscopy under nonparalyzing general anesthesia showed normal vocal cords. The whole trachea appeared to be flaccid and collapsing during expiration. The main right and left bronchi showed similar features, although more pronounced on the left. Under radiologic screening, two noncovered Ultraflex self-expanding metal stents (Boston Scientific, Natick, MA) were deployed to the trachea (18 x 40 mm) and the left main bronchus (16 x 40 mm). The immediate postoperative recovery was complicated by retention of secretions despite aggressive chest physiotherapy. Six days after the procedure the patient had severe shortness of breath develop and her oxygen saturation level dropped to below 80% on FiO
2 70%. Subsequent rigid bronchoscopy demonstrated migration of the tracheal stent into the proximal end of the left main bronchial stent, and the origin of the left bronchus was largely obstructed by mucous plug. Severe collapse of the right main bronchus and mucous plugging was worse than judged earlier.
In view of the previous findings, the Ultraflex tracheal stent was explanted and replaced by a noncovered Gianturco self-expanding metal stents (20 x 50 mm). The right main bronchus was stented afresh using a similar Gianturco stent (15 x 50 mm; William Cook), and the left main bronchus Ultraflex tracheal stent was left in situ. It was believed that the Gianturco stents might offer more rigid support to the central airways, reducing the dynamic collapse. Subsequent postoperative recovery was uneventful.
Four months later the patient re-presented with her first episode of right pneumothorax (Fig 1) successfully treated by aspiration. Two months later she presented with a second episode of right pneumothorax. Further rigid bronchoscopy showed the Gianturco stent in the right main bronchus to be well seated and distal to that of the middle lobe origin, which was completely obstructed by mucous plug. The tracheal stent framework (Fig 2) dented the membranous part of the trachea posterolaterally suggesting perforation of the tracheal wall. In view of her comorbidities she was treated with talc slurry pleurodesis through an intercostal drain. The air leak stopped and the right lung fully expanded, which allowed full recovery. Three months after discharge she unfortunately had massive haemoptysis develop at home and died shortly after admission to hospital. Postmortem examination confirmed a portion of the metallic stent to have eroded through the tracheal wall into the left subclavian artery causing a fatal bleed.
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Fig 1. Right pneumothorax with subcutaneous emphysema. Tracheal and bronchial stent can also be seen. Small arrows illustrate the outline of the pneumothorax. The long arrow shows the tracheal stent in situ.
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Comment
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In 1952, Harkins [5] described the first usage of endotracheal prosthesis for the treatment of tracheal stenosis. Since then many prosthesis of different materials have been used with varying degrees of success [2, 6, 7]. Although tension pneumothorax has been described as an immediate complication of stent placement [2, 6, 7], we believe that this is the first report of late and recurrent pneumothoraxes heralding fatal bleeding due to fracture of a stent metal framework. Our patient had two episodes of right pneumothoraxes at 4 and 6 months post-stent insertion. Metal fatigue resulted in spontaneous breakage of the metal framework, leading to a sharp end of the wire piercing through the membranous part of the trachea into the right mediastinal pleura and possibly the right lung. The natural excursions of the trachea during breathing kept the sharp end of the wire in continuous motion, allowing re-injury and recurrence of pneumothorax, and ultimately fatal bleeding.
Balloon-expandable metal stents are more likely to erode the tracheobronchial tree and lacerate major blood vessels. Systematic review of the literature identified other types of self expanding metal stents attributable to fatal bleeding, such as Palmaz (Johnson & Johnson Interventional Systems Co, Warren, NJ) [8] and Polyflex (Boston Scientific Corp, Natick, MA) [9], yet it is primarily the Gianturco self-expanding metal stent that is associated with this complication. Whereas migration and erosion account for the fatal bleed in other stents, metal framework fracture seems to be unique to Gianturco stents bleeds. The largest published series in the United Kingdom reporting results of Gianturco tracheal stents comes from Liverpool [1] and seems to find them safe. Some experts are of the opinion that Gianturco stents should not be used to treat tracheal stenosis [10], especially for tracheomalacia [11].
Once deployed, Gianturco stents should only be removed surgically according to the manufacturer’s instructions. In view of our patient’s comorbidities, a talc slurry pleurodesis was contemplated to save the patient a thoracotomy. Ongoing erosion however led to the fatal perforation of the left subclavian artery.
Late pneumothorax in a patient with tracheal stent should raise the suspicion of stent fracture and should be regarded as extremely serious, on a par with massive haemoptysis. Recurrence of pneumothorax should be considered as an absolute indication for surgical extraction of the stent. Since the occurrence of this complication our practice has changed. We no longer use Gianturco self-expanding metal stents for benign pathology, and we resorted to implanting bronchoscopically removable metal stents (Nitinol self-expanding metal stents; Niti-S, Taewoong Inc, Seoul, Korea).
In conclusion, metallic tracheobronchial stents should be considered very carefully in managing nonmalignant large airway obstruction. Gianturco self-expanding metal stents are being challenged with regard to treating tracheomalacia. Late recurrent pneumothorax is a very serious complication of the Gianturco self-expanding metal stent framework fracture and must be considered on a par with near-fatal bleeding. We advocate prompt removal of the Gianturco stent and replacement with a softer type of metal stent that can be removed bronchoscopically should the need arise.
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References
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- Stockton PA, Ledson MJ, Hind CRK, Walshaw MJ. Bronchoscopic insertion of Gianturco stents for the palliation of malignant lung disease: 10 year experience Lung Cancer 2003;42:113-117.
- Davis N, Madden BP, Sheth A, Crerar-Gilbert AJ. Airway management of patients with tracheobronchial stents Br J Anaesth 2006;96:132-135.
- Noppen M, Stratakos G, D’Haese J, Meysman M, Vinken W. Removal of covered self-expandable metallic airway stents in benign disorders: indications, technique, and outcomes Chest 2005;127:482-487.
- Gaissert HA, Grillo HC, Wright CD, Donahue DM, Wain JC, Mathisen DJ. Complication of benign tracheobronchial strictures by self-expanding metal stents J Thorac Cardiovasc Surg 2003;126:744-747.
- Harkins WB. An endotracheal metallic prosthesis in the treatment of stenosis of the trachea Ann Otol Rhinol Laryngol 1952;61:932-935.
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- Cook CH, Bhattacharyya N, King DR. Aortobronchial fistula after expandable metal stent insertion for pediatric bronchomalacia J Pediatr Surg 1998;33:1306.
- Nouraei SM, Pillay T, Hilton CJ. Emergency management of aorto-bronchial fistula after implantation of a self-expanding bronchial stent Eur J Cardiothorac Surg 2001;20:642.
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- Hramiec JE, Haasler GB. Tracheal wire stent complications in malacia: implications of position and design Ann Thorac Surg 1997;63:209-212.
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Abstract
Introduction
