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J Thorac Cardiovasc Surg 1994;107:957-959
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
Departments of Vascular, Thoracic, and Cardiac Surgery
University of Ulm
Ulm/Donau, Germanya
To the Editor:
Short tracheobronchial stenoses are usually treated by surgical resection However, there are two main groups of nonresectable long tracheal stenosis: tracheomalacia with unstable walls and long stenoses caused by extensive mediastinal tumor infiltration. There is a large experience with silicone stents for therapy of short stenoses, including anastomotic insufficiencies,tracheoesophageal fistulas, and airway compression from peritracheal or peribronchial tumor growth.
1 Endoscopic placement of endotracheal stents as emergency treatment may alleviate distressing symptoms immediately, but several factors limit effective long-term use of conventional silicone stents: (1) any type of stent needs to dilate the trachea slightly to prevent narrowing of the airway lumen through the wall thickness of the implanted stent; (2) the stent may disturb mucus transport; and (3) dislocation of the stent may occur.
A new concept was introduced with the development of self-expanding metallic stents, which were originally designed for use in pathologic blood vessels but have also been used clinically in the tracheobronchial system. 2-4 A special type of self-expanding stent (Wallstent; Schneider AG, Lausanne, Switzerland) is made of steel monofilament wire braided in a tubular mesh configuration. It has also been successfully used for treatment of atherosclerotic vascular or biliary stenosis. In a recent report, this stent has been used in combination with silicone elastomer stents for tracheobronchial strictures. 5 We report the use of tracheoscopic balloon dilation in combination with sequential implantation of this self-expanding stent as effective long-term therapy for an inoperable long tracheal stenosis caused by a large mediastinal tumor.
A 55-year-old male patient had progredient dyspnea and cough. Seven years previously, complete bilateral thyroidectomy had been performed in another hospital because of a follicular carcinoma of the thyroid gland. On physical examination, a prolonged inspiration was noticed. A chest roentgenogram showed a large mediastinal tumor metastasis of the follicular carcinoma, 10 cm in diameter. In computed tomographic scans, the tumor extension was found to reach from the supraclavicular region to the right main bronchus and to the cervical vertrebral column, the mediastinum was shifted to the left with esophageal and tracheal compression, and the tracheal wall seemed to be infiltrated by the tumor. Tracheobronchoscopy showed that the tracheal lumen was narrowed to 4 mm over a distance of 9 cm without signs of intraluminal tumor infiltration; multiple biopsy and cytologic probe samples contained no malignant cells. The esophagus was also compressed in the middle third without infiltration of the mucosa (as confirmed by multiple biopsy samples).
A pulmonary function test gave the following results. Arterial oxygen tension was 66 mm Hg under resting conditions. Vital capacity was 4370 ml (79% of predicted), with normal value for pulmonary resistance (<0.3 kPA· sec/L). The residual volume was 5520 ml (179%) after bronchodilation with sultanol 5120 ml. Forced expiratory volume was 3.32 L and forced inspiratory volume was 1.56 L. This was interpreted as a functionally relevant airway obstruction. The patient was transferred to our department. Surgical resection of the mediastinal tumor was not considered possible and palliative treatment was initiated.
By means of a rigid tracheoscope and under fluoroscopic control, probing dilation of the stenotic tracheal segment was performed with an 18 mm balloon dilatator. After tracheoscopic visualization of the resulting adequate diameter, a self-expanding metallic mesh stent (Wallstent; length, 77 mm;diameter, 16 mm) was positioned and allowed to expand by retraction of the outer membrane. A final dilation of the trachea and stent was then performed to obtain a diameter of 18 mm (Fig. 1). At the end of anesthesia, the patient felt subjective improvement immediately. Clinically, no stridor was present, and the patient was discharged 2 days later. Control of lung function gave the following results: vital capacity, 4130 ml, forced expiratory volume 2800 ml (both unchanged), and forced inspiratory volume, 2860 ml (improved). Mediastinal irradiation of the tumor was begun.
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If stents are used in patients with tracheomalacia, they must possess elastic properties to prevent deformation. The decision to use an self-expanding stent should consider the fact that this type of stent cannot be removed, which may limit its use for palliative therapy in patients with unresectable stenosis. In the case of tumor in growth through the metallic mesh, 5 laser vaporization is no longer possible thenbecause of changes in the physical properties of the metal after heat development; other treatment modalities may therefore be preferable in these cases. Tracheomalacia or other forms of tracheal stenosis that can be dilated are good indications for probing endoscopic balloon dilation in combination with self-expanding metallic stents, and our experience with five patients encourages further clinical use of this combined technique.
References
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