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Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-24, Cleveland, OH 44195
(Email: murthys1{at}ccf.org).
Obstructing tracheobronchial disease, particularly when resection and reconstruction is not an option, poses significant management difficulty. The cause is largely malignant or a sequela of cancer treatment (eg, radiation induced), although systemic inflammatory disease is occasionally implicated. Length of involved airway, patient fitness, disseminated malignancy or prior therapy, or a combination of these can affect treatment options, which are generally palliative and primarily center on restoration of airway patency through endobronchial stenting.
Stents are broadly divided into silicon-expanding and self-expanding metallic types [1, 2], and both have liabilities. Silicon stents require general anesthesia and rigid bronchoscopy, migrate frequently, inspissate mucus, and can granulate. Metallic stents are deployable using a flexible bronchoscope, but may suffer from metal fatigue and stent fracture, and are more commonly beset with obstructing granulation tissue that requires unscheduled reintervention.
Self-expanding technology is particularly attractive for cases in which the airways are friable and tenuous because metallic stents are passed over guidewires under fluoroscopic control without disrupting the tissues, which may be expected with rigid bronchoscopy. The ease and accuracy of deploying self-expanding metallic stents (SEMS), as well as superior radial expansion make them particularly attractive for patients with intractable malignant airway strictures. Moreover, metallic stents are more likely to conform to the airway because of their inherent compliance.
Because SEMS are designed for purely linear application, stenting at and around the carina is difficult, if not impossible; thus silicon "Y" stents have been designed for this purpose. In this article, Drs Chen and Jiang [3], in conjunction with a local company, seem to have successfully created a self-expanding stent for application across the carina. Their technology involves customizing the tracheobronchial stent using measurements obtained from a high-resolution computed tomographic scan.
Appropriately, their early experience enrolled patients with high-grade carinal malignancies and essentially no other treatment options. Their results are remarkable for several reasons. Deployment of the stents seems to have been successful despite the complexity of the design. Importantly, all patients enjoyed a durable and meaningful response to the intervention. Finally, the other inherent qualities that make SEMS attractive for these types of patients do not seem to be compromised by the novel construction.
This new anatomy-conforming stent demonstrates promise for this challenging group of patients. It remains to be seen whether many of the problems complicating the use of standard SEMS will similarly confound the use of these novel prostheses. Nonetheless, this technologic achievement represents an important innovation in the development of endobronchial stents.
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