Migration of Gianturco expandable metallic stents in the upper trachea

Progressive experience in tracheal stenting with self-expandable stents

We experienced an unacceptably high 21% complication rate with the stainless steel Gianturco stent: a 68-month mean follow-up (range: 37-96 months) of 23 patients revealed three stent fractures and two migrations. Consequently, we began using nitinol mesh stents (Ultraflex) for fibrous stenoses and silicone-covered prostheses (Rush) for proliferative tracheal tumors. The extractable nitinol stent, made from alloy with thermal memory, was palliatively used in 15 patients with fibrous tracheal stenosis; the mean follow-up currently covers 21 months (range: 1-60 months). The silicone-covered prosthesis was used for two patients with inoperable tracheal tumor; follow-up covers 4 months and 2 months, respectively. The prostheses were positioned under visual guidance via the endoscopic approach. The median forced inspiratory volume in 1 s (FIV1) improved from 2.1 l/s (IQR: 0.7-2.4) to 3.2 l/s (IQR: 0.9-3.4) (P=0.018, Wilcoxon signed rank test). The median ratio of peak inspiratory flow (PIF 50%) to peak expiratory flow (PEF 50%) was 1.0 preoperatively (IQR: 0.8-1.5) and 1.8 postoperatively (IQR: 0.6-6.3). Between months 1 and 12, six granulomas developed. Five were treated with antibiotics and steroid aerosol inhalation therapy and one required CO2 laser vaporization. On day 10, one stent migration was observed. The migrated stent was substituted. To date, no stent fracture has been observed. Nitinol and silicone-covered prostheses can be proposed for the palliative treatment of fibrous tracheal stenoses and tracheal tumors, respectively.

Study on the treatment of tracheobronchial stenosis using expandable metallic stents

The purpose of this study is to clarify the clinical usefulness of Gianturco-Z stent (G-Z stent) for the management of malignant and benign tracheobronchial stenosis. Seventy-three stents were used in 30 patients. In 20 cases, we used the so-called "stent-in-stent" method. Twenty-four patients were grade 5, and 6 were grade 4 according to the Hugh-Jones classification of respiratory status. The technical success rates, clinical condition, respiratory status, blood gas analysis, survival rate, and complications were reviewed on the basis of the patients'medical records and radiographs. All stents were successfully placed in the appropriate position. After the procedure, respiratory status improved in 97% (29/30) of the patients. PaO(2) increased statistically (p<0.05), and PaCO(2) decreased one week after the treatment. Mean survival of 30 patients after stent placement was 123 days. Mean survival in 9 malignant patients treated in combination with radiotherapy (182 days) was statistically longer (p<0.01) than in those treated without radiotherapy (65 days, n=20). The tracheobronchial burn patient who received a combination of stent placement and post operative radiotherapy survived 540 days. No major complications were encountered during or after the procedure. Only 3 minor complications were observed: 1 stent migration, 1 partial rupture of the stent, and 1 stent deformation. G-Z stent treatment with the "stent-in-stent" technique is useful for palliation of malignant and benign tracheobronchial stenosis, and should contribute to improving the quality of life in patients with advanced cancer.

Stenting of the tracheobronchial tree

Endoscopic treatment of endobronchial obstructions is becoming increasingly important. Tracheobronchial stents often are needed in the treatment of obstructions from submucosal or extrabronchial lesions. Tube stents have been available since the early 1960s but are underused because their insertion requires the use of a rigid bronchoscope. With the recent development of metallic stents, interventional radiologists increasingly are involved in the treatment of tracheobronchial obstructions. Metallic stents, easily placed with flexible bronchoscopy, are growing in popularity. All available tracheobronchial stents have been shown in various clinical series to be able to achieve immediate resolution of respiratory symptoms from various tracheobronchial obstructions. A stent's performance, however, should not be based solely on short-term response. Presently, there is no ideal stent because none is free of complications and none are able to consistently maintain life-long patency. Gianturco stents are associated with serious major complications (bronchial perforations and strut fractures) and are no longer recommended for use in the tracheobronchial tree. The Palmaz stent has also fallen into disfavor, because a strong external force, such as a vigorous cough, can recompress it. The Strecker stent can only be used in smaller airways, but may be useful in the accurate stenting of short segment stenoses because it does not foreshorten on deployment. The Wallstent and Ultraflex are our present metallic stents of choice. Both are easy to deploy, available in covered forms, exert adequate radial force, remain relatively stable in position, and have good longitudinal flexibility for use in tortuous airways. Disadvantages include excessive granulation tissue formation and difficulty of removal once the stent has been epithelialized. Metallic stents should be chosen very carefully for use in benign lesions with ongoing active local inflammation or when temporary stenting is needed. In the absence of an ideal stent, technologic advancements will continue. Potential developments include removable metallic stents, biodegradable stents, and chemically and radioactively coated stents. Unquestionably, the expanding stent market will drive scientific research toward the development of the ideal stent. Clearly, physicians need to be ready to assess these technologic advancements.

Tracheobronchial strictures: treatment with a polyurethane-covered retrievable expandable nitinol stent--initial experience

A polyurethane-covered retrievable expandable stent was placed in 13 patients with tracheobronchial strictures. In four patients with benign strictures, the stent was removed with use of a retrieval hook 2-6 months after placement. After stent removal, three of the four patients did not need further treatment. The retrievable stent warrants further investigation in the treatment of tracheobronchial strictures.

Palliative treatment for tracheal stenoses using carbon dioxide laser and the Gianturco stent. Long-term results

Between September 1992 and March 1998, the self-expandable Gianturco prosthesis was inserted in 23 patients suffering from tracheal stenosis. After radial incision and dilation of the stenosis as described by Shapshay, the positioning of the stent was performed during an endoscopic procedure under optical control. The prosthesis used was a double-ring stent 50 mm long and 20 mm in diameter. The follow-up period ranged between 0.5 and 67 months with an average of 31 +/- 18 months. Pulmonary function tests showed an average improvement of the peak expiratory flow (50%) from preoperative results of 1.06 +/- 0.60 L/s to short-term postoperative results of 2.08 +/- 0.78 L/s and long-term postoperative results of 2.11 +/- 0.78 L/s. The mean peak inspiratory flow (50%) improved from 1.43 +/- 0.85 L/s to 2.40 +/- 1.29 L/s at short term and to 2.56 +/- 1.20 L/s at long term. Eight patients out of the 23 had to undergo a second endoscopic procedure: 3 patients for granuloma vaporization; 1 patient to change a malpositioned stent; 2 patients to add a second stent because of insufficient tracheal enlargement; and 2 patients to resect mucosal membranes between the 2 stent rings and to place a second stent. Optical control of the accurate positioning and use of this model of Gianturco prosthesis helped to avoid the severe complications described in the literature (migration, extrusion, fracture, wall erosion. and hemorrhage). The follow-up must particularly target the prevention of granulomas. The self-expandable Gianturco prosthesis can be advocated for long-term palliative treatment of tracheal stenoses that are inoperable by an external surgical approach.

Efficacy and complications of the Gianturco-Z tracheobronchial stent for malignant airway stenosis

PURPOSE

To describe our experience using the Gianturco Z-stent (G-Z stent) for the management of malignant tracheobronchial stenosis, with special reference to complications.

METHODS

Thirty-six stents were used in 22 patients with 28 lesions. Thirteen patients were grade 5 according to the Hugh-Jones classification. The technical success rates, follow-up results, and complications were reviewed on the basis of the patients' charts and radiographs.

RESULTS

All stents were successfully placed in the ideal position without procedure-related complications. After the procedure, respiratory status improved in 95% (21/22) of patients, and performance status improved in 77% (17/22). Mean survival after stent placement was 15 weeks. Four patients suffered from increased thick secretions requiring multiple suctioning and aspiration by bronchoscopy. One of these patients died from asphyxiation 2 weeks after placement. Stent disruption and/or migration was observed in six patients. Of these six, four experienced life-threatening hemoptysis; all four had received aggressive anticancer treatment.

CONCLUSION

G-Z stents are useful for palliation of malignant tracheobronchial obstruction. However, complications of stent strut fracture and migration give cause for concern.