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 Table of Contents  
EDITORIAL
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 4-5

Airway stents


Department of Pulmonary Medicine, Calcutta Medical Research Institute, Kolkata,West Bengal, India

Date of Web Publication23-Dec-2015

Correspondence Address:
Ranjan Kumar Das
Calcutta Medical Research Institute, 7/2, Diamond Harbour Road, Kolkata - 700 027, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.172483

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How to cite this article:
Das RK. Airway stents. J Assoc Chest Physicians 2016;4:4-5

How to cite this URL:
Das RK. Airway stents. J Assoc Chest Physicians [serial online] 2016 [cited 2021 Dec 7];4:4-5. Available from: https://www.jacpjournal.org/text.asp?2016/4/1/4/172483

Little must had the British dentist Charles R Stent [1] imagined when he invented, some 125 years ago, a compound to cast dental models and splints that his name would be used in various specialties for techniques and materials designed to establish a sufficient lumen in constricted tubular structures of the body. Today, airway stenting has become a common technique in the management of central airway obstruction (CAO). These are indicated in establishing patency in compressed or strictured central airways, for supporting weakened cartilages in cases of tracheobronchial malacia and for sealing tracheal or major bronchial fistulas.

Historically, surgical implantation of stents for the treatment of airway strictures were first performed by Trendelenburg (1872) and Bond (1891).[2] In 1965, Montgomery [3] designed a silicone rubber T-tube with an external side limb for the treatment of subglottic stenosis with tracheostomy. Since then, silicone became the most popular material for stents. However, insertion required surgical fixation after splitting the trachea. The real breakthrough came in 1990, when Dumon [4] presented a dedicated silicone tracheobronchial prosthesis that could be introduced with a rigid bronchoscope using a dedicated pusher. These silicone stents are straight with studs on the outer wall and these interfered little with the innate mucociliary mechanisms. These silastic stents became popular rapidly and had become the most frequently used stent worldwide. A recent addition is a Y-shaped Dumon stent, which is suited for palliating lower tracheal and carinal stenosis. Though the main advantage of Dumon stent is that it can be repositioned or removed anytime with ease, it requires general anesthesia and operator's skill in performing a rigid bronchoscopy.

The next major advancement came with the development of a new generation of stents that were metallic, self-expandable, and easily deployable via flexible bronchoscope, the so-called self-expandable metallic stents (SEMS), the Wallstent, and the Ultraflex stent (Boston Scientific) being the prototypes.[5] These stents provide outward radial force on the tracheal or bronchial wall which prevent migration. Special deployment systems have been developed for the placement of SEMS either through the flexible bronchoscope or over the guide wire. The traditional standard technique involved the use of fluoroscopic guidance to facilitate stent placement. In this regard, Madan et al have described their experience of a successful technique of SEMS insertion in malignant tracheal lesions without fluoroscopic guidance,[6] the article is now published as ahead of print (AOP) and will be published in the next issue of Journal of Chest Association of Physicians. This allows for simpler logistics and savings on manpower and time with results similar to a technique using image intensifier and fluoroscopic guidance.

Whereas, the art of stent placement may be considered a specialized skill and stents achieve dramatic airway patency bringing immediate relief, the real success of an airway stent depends on the awareness and management of complications. Migration, mucostasis, obstruction due to granulations or tumor growth, stent wire fracture, and perforation are the commonly encountered complications. Complications are rarely reported, and there is a need for multicenter audit for minor and major complications related to airway stenting. In India, where facilities for airway stenting are available in only a few referral centers in large metropolitan cities, and bronchoscopy services at most district level hospitals are nonexistent, it becomes absolutely imperative for airway stenting service providers to educate patients, particularly those who come from far-off regions, to detect early symptoms of potential complications.

Though SEMS can be used successfully in benign CAO, high-complication rate approaching 45% drew the attention of the Food and Drug Administration which issued and advisory in 2005 calling for restraint on the use of SEMS in benign CAO and this warning was fully supported by the Interventional and Chest Diagnostics Network Steering Committee of the American College of Chest Physicians.[5]

Colonization of stents by potentially pathogenic organisms is a reality, and stent-associated respiratory tract infections are reported to be as high as 20%. Pathogens included Pseudomonas, Staphylococcus aureus, Streptococcus pneumonia, and Klebsiella.[7] Mucus plugging is another common adverse event in patients with indwelling airway stents which may require immediate intervention.[8]

Choice of stent in CAO will depend on site, shape, length of stenosis, and whether primary condition is benign or malignant. If the primary condition is benign, a silastic tube stent is recommended since it is possible to remove, if required, at a later date. In malignant conditions, both SEMS and tube stents may be used. However, the ease of deployment of SEMS via a flexible bronchoscope makes it an ideal choice among interventional pulmonologists.

Stents, thus, have emerged as an important addition to the interventional pulmonologist's armamentarium for the management of CAO, tracheomalacias, and tracheal or major bronchial fistulas. Successful central airway stenting requires judicious selection of stent, its perfect deployment, and effective management of complications.

 
  References Top

1.
Freitag L. Tracheobronchial stents. In: Bolliger CT, Mathur PN, editors. Interventional Bronchoscopy, Progress in Respiratory Research. Vol. 30. Basel (Switzerland): Karger; 2000. p. 171-86.  Back to cited text no. 1
    
2.
Lee P, Kupeli E, Mehta AC. Airway stents. In: Mehta AC, editor. Interventional Pulmonology, Clinics in Chest Medicine. Vol. 31. Philadelphia: Saunders; 2010. p. 141-50.  Back to cited text no. 2
    
3.
Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82:320-1.  Back to cited text no. 3
[PUBMED]    
4.
Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:328-32.  Back to cited text no. 4
    
5.
Lund ME, Force S. Airway stenting for patients with benign airway disease and the food and drug administration advisory: A call for restraint. Chest 2007;132:1107-8.  Back to cited text no. 5
[PUBMED]    
6.
Madan K, Venkatnarayan K, Mohan A, Hadda V, Khilnani GC, Guleria R. Flexible bronchoscopic insertion of self-expanding metal stents in malignant tracheal lesions without fluoroscopic guidance. [Published online ahead of print October 2015]. J Assoc Chest Physicians. doi: 10.4103/2320-8775.168619.   Back to cited text no. 6
  Medknow Journal  
7.
Noppen M, Piérard D, Meysman M, Claes I, Vincken W. Bacterial colonization of central airways after stenting. Am J Respir Crit Care Med 1999;160:672-7.  Back to cited text no. 7
    
8.
Agrafiotis M, Siempos II, Falagas ME. Infections related to airway stenting: A systematic review. Respiration 2009;78:69-74.  Back to cited text no. 8
    



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