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Ann Thorac Surg 2008;85:1800-1802. doi:10.1016/j.athoracsur.2007.11.045
© 2008 The Society of Thoracic Surgeons
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Case Reports

Management of Tracheomediastinal Fistula Using Self-Expanding Metallic Stents

Chirag Choudhary, MD, Thomas R. Gildea, MD*, Reyadh Salman, MD, Enrique Diaz Guzman, MD, Atul C. Mehta, MBBS

Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio

Accepted for publication November 2, 2007.

* Address correspondences to Dr Gildea, Department of Pulmonary, Allergy, and Critical Care Medicine, A-90, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 (Email: gildeat{at}ccf.org).


Dr Mehta discloses that he has a financial relationship with Alveolus Corporation.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Tracheomediastinal fistula is a rare condition usually associated with a fatal outcome. We report the case of a 65-year-old man with a subcarinal mass causing total destruction of the carina and proximal mainstem bronchi. The mass was diagnosed as a large cell lymphoma, and the decision was made to undertake chemotherapy only after stabilization of the endobronchial tree. The endobronchial defects were successfully palliated with placement of three different types of self-expanding metallic stents using a flexible bronchoscope under conscious sedation. The unique properties of each stent were used for optimum clinical benefit, avoiding any morbidity.

Tracheomediastinal fistula formation is a rare condition with potentially grave complications. We report a case of large cell lymphoma involving fistulous tract formation between the trachea and bilateral mainstem bronchi. The endobronchial defects were successfully palliated with three different varieties of self-expanding metallic stents (SEMS) placed under conscious sedation using flexible bronchoscopy.

A 65-year-old man who was a lifelong nonsmoker was evaluated for a cough of 6 weeks' duration. The cough had failed to respond to a course of antibiotics and steroids. Computed tomography (CT) revealed a 45- x 30-mm mass eroding into the main carina and causing compression of the mainstem bronchi (Fig 1). Mediastinal and bulky right hilar adenopathy causing narrowing of the bronchus intermedius and the superior vena cava was also recognized. There was a right paratracheal lymph node invading the trachea. Flexible bronchoscopy revealed near complete destruction of the main carina, with a friable scrap of tissue remaining in the center (Fig 2A). The tracheomediastinal fistula involved the medial walls of both mainstem bronchi (Fig 2B). Endobronchial biopsies revealed high-grade lymphoma. Expecting good response to chemotherapy, stabilization of the endobronchial tree before the therapy was considered.


Figure 1
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  		Fig 1. Computed tomographic scan at the level of the carina revealing a large tracheomediastinal fistula. Note absence of medial walls of both mainstem bronchi.

 

Figure 2
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  		Fig 2. (A) The remnant of carinal tissue between the anterior and posterior tracheal wall. (B) A view of the mediastinum just below the remnant of the carina revealing the tracheomediastinal fistula involving the mainstem bronchi.

 
Flexible bronchoscopy was performed under conscious sedation using the transoral route. Under fluoroscopic guidance, a covered 12- x 40-mm and an uncovered 12- x 40-mm, Ultraflex stent (Boston Scientific Corp, Natick, MA) were placed in the left and right mainstem bronchi, respectively, and positioned to approximate their proximal ends to reinforce the remnant of main carina. An 18- x 40-mm Alveolus stent (Alveolus Inc, Charlotte, NC) was deployed in the distal trachea to abut the bronchial stents and avoid proximal migration (Fig 3). Total patency of the trachea and main bronchi was established. There were no complications, and the patient reported improvement in his symptoms. He was discharged home on albuterol and acetylcysteine aerosol treatments. The patient continues to live a symptom-free life on chemotherapy 2 months after placing the stents.


Figure 3
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  		Fig 3. Flexible bronchoscope image after self-expanding metallic stent insertion, reveals the distal end of the Alveolus stent in the trachea abutting the Ultraflex stents placed in the right and left mainstem bronchi respectively. The Ultraflex stents are approximated proximally to reinforce the main carina and cover the tracheomediastinal fistula.

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Primary mediastinal involvement with lymphoma is uncommon (10%) [1]. Mediastinal involvement with Hodgkin's lymphoma could be associated with compression of the superior vena cava, bleeding, and fistula formation with the adjacent luminal structures [2]. A case of a tracheomediastinal fistula in the same condition has also been cited, in which the defect was repaired with an autogenous pericardial patch [3].

We describe a case of managing a tracheomediastinal fistula caused by lymphoma, using SEMS placed through a flexible bronchoscope. Use of SEMS for repair of an iatrogenic tracheomediastinal fistula has been previously reported [4]. The SEMS have been used for a variety of central obstructing lesions [5], to seal tracheoesophageal fistulae, and for anastomotic complications after lung transplantation [6].

In our case owing to the extensive involvement of the trachea and bilateral mainstem bronchi, the decision was made to use three different SEMS. These devices were believed to be the appropriate choice as they did not require any rigid instrumentation or use of positive-pressure ventilation. We thought that this was essential to avoid any further extension of the defect. The procedure was performed using a flexible bronchoscope under conscious sedation and local anesthesia maintaining spontaneous breathing. As there was no cartilage supporting the carina, we believed that a silicone Y stent might be at a great risk of migration into the mediastinum.

An uncovered Ultraflex stent was placed in the right mainstem bronchus and bronchus intermedius to provide structural integrity, promote granulation tissue formation or neoepithelialization [7], and also to maintain ventilation to the right upper lobe, intentionally covered by the device. This stent would also allow drainage of secretions from the mediastinum. A covered stent was placed in the left mainstem bronchus, in attempt to reduce the size of the defect while maintaining the structural integrity. Both the stents were then approximated proximally to reinforce the main carina and hopefully promote granulation tissue formation [6]. The Alveolus stent was placed in the distal trachea abutting the two Ultraflex stents anteriorly to avoid their proximal migration as the proximal medial wall of both mainstem bronchi was absent. This fully covered stent would also provide support against tracheal invasion of the right paratracheal lymph node as well as reduce the size of the fistula involving the lower part of the trachea (Fig 3).

In summary, we chose three different types of SEMS to successfully manage a complex tracheomediastinal fistula in which a surgical repair was clearly not an option. We also avoided use of positive-pressure ventilation as well as rigid instrumentation, which could extend the defect. This case illustrates the advantage of using flexible bronchoscopy and SEMS for diagnosis and successful stabilization of the endobronchial tree, respectively, in a patient with mediastinal lymphoma. We hope that these stents are temporary and may be removed in the future depending on the response to chemotherapy and stent-related granulation tissue formation.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Lichtenstein AK, Levine A, Taylor CR, et al. Primary mediastinal lymphoma in adults Am J Med 1980;68:509.[Medline]
  2. Greven KM, Evans LS. The occurrence and management of esophageal fistulas resulting from Hodgkin's disease Cancer 1992;69:1031-1033.[Medline]
  3. David GT, Summers A, Sanger JR, Haasler GB. Surgical treatment of tracheomediastinal fistula from recurrent Hodgkin's lymphoma Ann Thorac Surg 1999;67:832-834.[Abstract/Free Full Text]
  4. Ranes JL, Budev MM, Murthy S, Mehta AC. Management of tracheomediastinal fistulas using self expanding metallic stents J Thorac Cardiovasc Surg 2006;131:748-749.[Free Full Text]
  5. Saad CP, Murthy S, Krizmanich G, Mehta AC. Self expanding metallic airway stents and flexible bronchoscopy: long term outcome analysis Chest 2003;124:1993-1999.[Medline]
  6. Mughal M, Gildea TR, Murthy S, Pettersson G, DeCamp M, Mehta AC. Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence Am J Respir Crit Care Med 2005;172:768-771.[Abstract/Free Full Text]
  7. Jantz MA, Silvestri GA. Silicone stents versus metal stents for management of benign tracheobronchial disease: pro: metal stents J Bronchol 2000;7:177-183.



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This Article
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