AJR 2005; 184:225-226
© American Roentgen Ray Society
Percutaneous Transtracheal Approach for Endobronchial Stenting
Syed A. Raza1,
Eric Walser1,
Alberto Hernandez1 and
Orhan Ozkan1
1 All authors: Department of Radiology, University of Texas Medical Branch, 301
University Blvd., Galveston, TX 77555-0709.
Received February 25, 2004;
accepted after revision April 16, 2004.
Address correspondence to S. A. Raza
(saraza{at}utmb.edu).
Introduction
Tracheobronchial stenting for airway strictures traditionally has been done
by using bronchoscopy with or without fluoroscopic guidance while the patient
is under general anesthesia. Common indications for airway stenting include
malignant strictures secondary to primary or metastatic disease and benign
anastomotic strictures in settings of lung transplant or strictures after
prolonged tracheal intubation. Other benign indications for tracheobronchial
stenting include infection, congenital lesions, mediastinal fibrosis,
relapsing polychondritis, Wegener's granulomatosis, and tracheomalacia
[1], although stenting in
benign airway disease recently has been challenged by Gaissert et al.
[2] due to complications that
follow the use of metal stents in airways and thus preclude definitive
surgical treatment in some cases.
The single most important factor in deciding whether to perform airway
stenting is the presence of a patent airway distal to the obstruction.
Strictures that respond well to treatment typically are those due to
extraneous compression or intramural pathology. Intraluminal lesions are
treated preferentially with ablation because of their tendency to recoil after
balloon dilatation and the possibility of rapid tumor ingrowth after stenting.
We describe a percutaneous transtracheal technique of stenting airways that
eliminates the need for using general anesthesia and bronchoscopy.
Materials and Methods
Over a 2-year period, seven patients (four men and three women) with a mean
age of 59.7 years were referred to interventional radiology for bronchial
stenting. All patients had unresectable lung cancer and shortness of breath
due to lung collapse distal to the tumor. Overall, 10 stents were placed in
seven patients with three patients receiving more than one stent because of
the multiplicity of airways involved. Patients with lung cancer invariably
have a history of smoking and suffer from some degree of emphysema; however,
this did not affect the choice of endoscopic versus percutaneous method of
bronchial stenting.
Results
Bronchial stenting was technically successful in all patients. All patients
experienced symptomatic relief from dyspnea.
Discussion
Tracheobronchial stenting has been used successfully for symptom relief in
patients with dyspnea due to malignant and benign strictures in large airways
[3–5].
The technical improvements during the last few years have resulted in smaller
profiles of the delivery systems and flexible, easily trackable
"over-the-wire" stents. This allows stenting as far as the
second-generation airways and, more proximally, trachea and mainstem bronchi.
The procedure usually is performed by an interventional radiologist in
collaboration with a pulmonologist or by the pulmonologists alone. It requires
bronchoscopy using a rigid or flexible scope and general anesthesia or heavy
sedation, which technically can be challenging for any anesthesiologist
[6]. On a busy day in an
interventional radiology suite, it takes a lot of valuable time to set the
room for anesthesia and for the pulmonologist and radiologist to work in
collaboration to complete the procedure.
Using the percutaneous transtracheal approach, we were able to perform all
procedures in an interventional suite, using conscious sedation and viscous
lidocaine for local anesthesia within the tracheobronchial tree. CT was
available for all patients' preprocedure examinations and was used for
preliminary stent planning and delineating airway anatomy
[1]. Patients were placed
supine on the fluoroscopy table and draped and prepared using an aseptic
technique. Sonography was used to visualize the thyroid isthmus and exclude
any large collateral veins in the suprasternal notch. IV conscious sedation
was administered using a combination of fentanyl and midazolam. After this, a
micropuncture needle was directed between tracheal rings in the region of the
suprasternal notch under fluoroscopic guidance. Viscous lidocaine (1–2
mL to a maximum of 15–20 mL) was injected immediately on entry into the
trachea via insertion of a 4- to 5-French sheath over guidewire. A stiff
hydrophilic wire was introduced and a larger vascular sheath (7- to 12-French)
was introduced depending on the size and make of deployed stent. A 4- to
5-French Bernstein catheter was introduced using the wire, and nonionic
contrast medium (iohexol, Omnipaque, Nycomed) mixed with a small amount of
lidocaine, was injected proximal to the strictured airway to obtain a
bronchogram (Figs. 1A,
1B,
1C, and
1D). The hydrophilic wire was
used to negotiate the stricture followed by a catheter, and contrast medium
was injected to visualize the distal margin of the lesion, measure length of
the stricture, and assess the distal bronchial tree. As soon as the airway
distal to stricture was entered, 1–2 mL of lidocaine was used again to
suppress the cough reflex from irritation of bronchial mucosa. The diameter of
the stent required was obtained by measuring the normal proximal segment of
the narrowed airway or by measuring a normal corresponding airway in the
opposite lung. A balloon was used to predilate tight strictures and, under
fluoroscopic guidance, an appropriate self-expanding stent was deployed in the
narrowed airway (Figs. 1A,
1B,
1C, and
1D). We have used
self-expanding Luminex stents (Bard) and Gianturco-Z stents (Cook) to treat
airway strictures. There have been reports of complications such as stent
fracture and stent migration in treatment of bronchial strictures with
Gianturco-Z stents [7], though
we did not encounter any of these problems in our patients.
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —68-year-old man with cancer in right lung. Transtracheal
bronchogram shows complete occlusion of right main bronchus distal to carina
with total collapse of right lung. Left bronchus is patent, and left lung is
well aerated.
|
|
View larger version (100K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —68-year-old man with cancer in right lung. Two guidewires
(white lines) have been placed through sheath into right upper-lobe
bronchus and bronchus intermedius. Bronchogram across narrowed airway shows
distal margin of stricture, assessment of stent size required, and patent
distal airways.
|
|
View larger version (148K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —68-year-old man with cancer in right lung. Bronchogram shows
upper-lobe stent is in place; notice immediate expansion of right upper lobe
compared with completely collapsed right lung in A. Lower lobe stent is
seen just before balloon dilatation.
|
|
View larger version (118K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —68-year-old man with cancer in right lung. CT scan of thorax
at lung window settings, 6 weeks after stent placement, shows most of right
lung is well aerated. Bilateral small pleural effusions are present.
|
|
The sheath is removed at the end of the procedure and a petroleum jelly
(Vaseline, Unilever) gauze dressing was applied to cover the entry site. The
average time for procedures in this series was 90 min.
In our initial experience, the patients' coughing due to irritation of
tracheobronchial mucosa during the procedure was a concern, but this was
overcome by generous use of viscous lidocaine and better conscious sedation.
As a result, patients in the latter half of the series did not experience this
discomfort. One case of postprocedure pneumomediastinum resolved
spontaneously.
We conclude that the percutaneous transtracheal approach is a safe and
effective option in treating tracheobronchial strictures. The transtracheal
technique should be used carefully in patients who have airway strictures
proximal to the carina and whether to choose the endoscopic or percutaneous
approach should be based on the location of stricture and space available to
maneuver wires and catheters if the transtracheal approach is used.
References
- Lehman JD, Gordon RL, Kerlan RK, et al. Expandable metallic stents
in benign tracheobronchial obstruction. J Thorac
Imaging 1998;13:105
-115[Medline]
- 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 Surg2003; 26:744
-747
- Wood DE, Liu YH, Vallieres E, Karmy-Jones R, Mulligan MS. Airway
stenting for malignant and benign tracheobronchial stenosis. Ann
Thorac Surg 2003;76:167
-172, discussion 173-174[Abstract/Free Full Text]
- Tanigawa N, Sawada S, Okuda Y, Kobayashi M, Mishima K. Symtomatic
improvement in dyspnea following tracheobronchial metallic stenting for
malignant airway obstruction. Acta Radiol2000; 41:425
-428[Medline]
- Vonk-Noordegraaf A, Postmus P, Sutedja T. Tracheobronchial stenting
in the terminal care of cancer patients with central airway obstruction.
Chest 2001;120:1811
-1814[Abstract/Free Full Text]
- Conacher ID. Anaesthesia and tracheobronchial stenting for central
airway obstruction in adults. Br J Anaesth2003; 90:367
-374[Abstract/Free Full Text]
- Nakajima Y, Kurihara Y, Niimi H, et al. Efficacy and complications
of the Gianturco-Z tracheobronchial stent for malignant airway stenosis.
Cardiovasc Intervent Radiol1999; 22:287
-292[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
J. H. Kim, J. H. Shin, H.-Y. Song, T. S. Shim, C. J. Yoon, and G.-Y. Ko
Benign Tracheobronchial Strictures: Long-Term Results and Factors Affecting Airway Patency After Temporary Stent Placement
Am. J. Roentgenol.,
April 1, 2007;
188(4):
1033 - 1038.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Shin, H.-Y. Song, C. J. Yoon, J. H. Kim, J.-O. Lim, Y. J. Kim, and H.-K. Ko
Bronchial catheterization with a TIPS dilator after failure of conventional technique.
Am. J. Roentgenol.,
September 1, 2006;
187(3):
W299 - W301.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Materials and Methods
