Fixation of silicone stents in the subglottic trachea: preventing stent migration using a fixation apparatus

Subcutaneous fixation model for complex stenting of recurrent laryngotracheal stenosis

BACKGROUND

A straight silicone stent can be used to treat proximal benign tracheal stenosis in non-surgical candidates. However, stent migration is a common complication when placed at a particular location and can lead to major complications. This case series of laryngotracheal stenosis reports a fixation method for straight silicone stents in the subglottic trachea (Stage 3 of the McCaffrey classification).

METHODS

The medical charts of these patients scheduled for straight silicone stent placement with suture fixation between 2014 and 2020 at the CHU UCL Namur Hospital (Belgium) were retrospectively reviewed. The procedure was performed using a rigid bronchoscope. Details of the procedure were obtained from medical records.

RESULTS

This case series included six patients (males: 4, females: 2). The median patient age was 59 years. Two suture fixations were placed following previous silicone stent migration episodes, whereas the others were placed proactively to avoid this risk. All fixations were performed by the device Freka® Pexact II ENFIt®, originally developed for gastropexy in endoscopic gastrostomy. The sutures were subcutaneously buried.

CONCLUSIONS

During the 6-month follow-up period, complications such as fixation issues and stent migration were reported despite the off-label use of the treatment. The straight silicone stent fixation technique used in this case series was simple and effective for securing the stent in upper benign tracheal stenosis.

Effects of shape and structure of a new 3D-printed personalized bioresorbable tracheal stent on fit and biocompatibility in a rabbit model

To date, several types of airway stents are available to treat central airway obstructions. However, the ideal stent that can overcome anatomical, mechanical and microbiological issues is still awaited. In addition, therapeutic effect and self-elimination of these stents are desirable properties, which pose an additional challenge for development and manufacturing. We aimed to create a prototype bioresorbable tracheal stent with acceptable clinical tolerance, fit and biocompatibility, that could be tested in a rabbit model and in the future be further optimized to enable drug-elution and ensure local therapeutic effect. Twenty-one New Zealand White Rabbits received five different types of bioresorbable tracheal stents, 3D-printed from poly(D,L-lactide-co-ε-caprolactone) metacrylates. Various configurations were tested for their functionality and improved until the best performing prototype could undergo detailed in vivo assessment, regarding clinical tolerance, migration and biocompatibility. Previously tested types of 3D printed stents in our preliminary study required improvement due to several problems, mainly related to breakage, unreliable stability and/or migration within the trachea. Abandoned or refined pre-prototypes were not analyzed in a comparative way. The final best performing prototype stent (GSP2 (Group Stent Prototype 2), n = 8) allowed a transoral application mode and showed good clinical tolerance, minimal migration and acceptable biocompatibility. The good performance of stent type GSP2 was attributed to the helix-shaped surface structure, which was therefore regarded as a key-feature. This prototype stent offers the possibility for further research in a large animal model to confirm the promising data and assess other properties such as bioresorption.

The "Hitch-Stitch" for Preventing High Tracheal Stent Migration: Expanding Indications and Extended Experience

BACKGROUND

Airway stenting is a standard treatment option for tracheo-bronchial obstruction and other conditions like tracheo-esophageal fistula (TEF).

METHODS

To prevent stent migration, a percutaneous fixation strategy called the "hitch-stitch" was described in 2016 as an efficient technique. We describe an extended experience of the "hitch-stitch" for silicone stents in high tracheal stenting situations and expanding indications to metal stents.

RESULTS

Seventy-four percutaneous stitches were placed in 54 patients (36 males and 18 females). The mean age of the patients was 42 (±19) years. The indication for stenting was tracheal stenosis in 63/74 (85%) cases and TEF in 11/74 (15%) cases. Silicone stents were used in 56/74 (75.5%) cases while self-expanding metal stents (SEMS) were used in 18/74 (24.5%) cases. The majority of the stents (62/74, 85%) were high tracheal stents. The "hitch-stitch" as an anti-migration strategy had a high success rate, with distal stent migration in only 2 cases (2.7%) as the stitch had given way-these were repositioned and hitched with double stitches. Minor complications included delayed skin healing (2.8%) and suture site infection (1.4%), which was successfully managed with oral antibiotics. Stitch removal was easy with no complications.

CONCLUSION

In this large series of percutaneous "hitch-stitch" as a stent migration prevention strategy, long-term data shows it is safe and effective in an expanded cohort of silicone stents. Its extended utility is the successful application to metal stents, especially in TEF, where the consequences can be deleterious. It is simple to do, with minimal extra requirements and not associated with any significant complications.

Novel technique for fixing tracheal stents

Endoscopic management of benign or malignant airway obstructions sometimes requires stenting after dilatation or debulking of the tumor. Straight stents are highly prone to migration in the trachea and the main bronchus, with potential catastrophic consequences. Multiple fixation strategies have been described to secure subglottic stents, each having certain limitations. This report describes a novel, "inside-to-outside" stent fixation in the upper airway using the Lichtenberger needle carrier (LNC) in 2 consecutive patients.

Preliminary Experience With a Novel Metallic Segmented Transcordal Stent Modified With Three-Dimensional Printing for Inoperable Malignant Laryngotracheal Stenosis

Background

This study aims to assess the feasibility of a novel metallic segmented transcordal stent modified with three-dimensional (3D) printing for treating inoperable malignant laryngotracheal stenosis and the tolerability of the stent.

Methods

This was a retrospective study. The stents were individually customized with the aid of 3D printing model based on the anatomic features of each patient’s airway. The stent was composed of two separate segments that corresponded to the larynx and the upper trachea. The stents were barrel-shaped at the proximal end to prevent migration. The proximal end of the stent was located slightly above the vocal cord. The technical and clinical success of stenting procedure, patient tolerability, and stent-related complications of patients were evaluated.

Results

Ten patients with dyspnea caused by malignant laryngotracheal stenosis underwent implantation of such stents. Technical and clinical success of the stenting procedure were achieved in all patients. For all patients, basic communication in life could be maintained by speaking softly. During follow-up, one patient showed intolerance to the stent, and the stent was retrieved 2 weeks after stenting. Stent migration was found in one patient, and the position of the stent was readjusted. Granulation tissue proliferation was found in two patients and was treated with cryotherapy by bronchoscopy. There were no deaths associated with stenting.

Conclusions

The individually customized metallic segmented transcordal stent is feasible and tolerable for patients with inoperable malignant laryngotracheal stenosis. The implantation of this stent may serve as a novel alternative treatment for patients who are not suitable for surgery or tracheotomy.

Double hitch stitch is a novel technique for fixation of tracheal stent in a case of tracheoesophageal fistula: a case report

Background

Caudal tracheal stent migration can be potentially life threatening by causing distal luminal obstruction. We present a rare double hitch stitch procedure (for prevention of migration of tracheal stent), which is an external fixation technique in a case of tracheoesophageal fistula with tracheal and esophageal self-expandable metallic stent (SEMS).

Case presentation

A 50-year-old male patient who presented with cough and dyspnea was a known case of carcinoma of the esophagus with esophageal stent in situ. Computed tomography (CT) scan showed tracheoesophageal fistula with esophageal stent (esophageal SEMS) migrating into the trachea. Tracheal stenting was done with SEMS. Patient was followed up after 1 month with recurrent complaints of cough on deglutition. On follow-up bronchoscopy, migration of stent was observed. A rare procedure of double hitch stitch was performed with fixation of the tracheal stent (tracheal SEMS) using a percutaneous anchoring stitch, embedded in the subcutaneous tissue. Follow-up bronchoscopy after 1 month of the procedure showed no migration of stent.

Conclusion

For the treatment of large tracheoesophageal fistula, stenting of both the trachea and the esophagus along with the double hitch stitch proved to be lifesaving. Stent migration prevention using “double hitch-stitch” is simple, safe, and successful, without any complications.

External fixation of airway stents for upper tracheal stenosis and tracheoesophageal fistula

OBJECTIVES

Stent migration is a common complication of airway stent placement for upper tracheal stenosis and tracheoesophageal fistula. Although several researchers have reported that external fixation is effective in preventing stent migration, the usefulness and safety of external fixation have not been proved because their cohorts were small. We therefore investigated the efficacy and safety of external fixation during upper tracheal stenting.

METHODS

Records of patients who underwent airway stent placement from May 2007 to August 2018 in a single centre were retrospectively reviewed. We included only patients whose stent had been placed in the upper trachea with external fixation to the tracheal wall. The primary endpoint of this study was the rate of stent migration.

RESULTS

Altogether, 51 procedures were performed in 45 patients (32 males, 13 females; median age 60 years, range 14-91 years). The median follow-up period was 9 months (range 0.3-90 months). Among the procedures, 15 were performed for benign disease and 36 for malignancy. Stents were composed of either silicone (n = 42) or metal (n = 9). Stent migration occurred in 3 (6%) patients. The stents with migration were all composed of silicone. Other sequelae were granulation tissue formation in 10 (20%) patients, sputum obstruction in 6 (12%), cellulitis in 3 (6%) and pneumonia in 1 (2%).

CONCLUSIONS

External fixation was an effective method for preventing migration of airway stents placed for upper tracheal stenosis and tracheoesophageal fistula. The complications were acceptable in terms of safety.

Airway stenting: Technological advancements and its role in interventional pulmonology

AS offers rapid and sustained relief of symptoms in most patients treated for malignant or benign CAO and can also be curative in itself in cases of benign tracheobronchial stenosis. In the past 30 years, this field has seen significant progress, from the misuse of vascular non-covered metallic stents to the development of silicone airway stents with an increasingly large panel of shapes and of hybrid, partially or fully covered, SEMS customized to the airways. This study aims to offer an overview on: (i) the respective advantages and drawbacks of these two main categories of devices; (ii) the main indications for AS and the rationale behind the choice of stent in each situation; and (iii) the main promises borne from the progress made in the field in the past few years, including the development of drug-eluting, biodegradable or patient-specific customized AS.

Idiopathic subglottic stenosis: a review

Idiopathic subglottic stenosis (iSGS) is a fibrotic disease of unclear etiology that produces obstruction of the central airway in the anatomic region under the glottis. The diagnosis of this entity is difficult, usually delayed and confounded with other common respiratory diseases. No apparent etiology is identified even after a comprehensive workup that includes a complete history, physical examination, pulmonary function testing, auto-antibodies, imaging studies, and endoscopic procedures. This approach, however, helps to exclude other conditions such as granulomatosis with polyangiitis (GPA). It is also helpful to characterize the lesion and outline management strategies. Therapeutic endoscopic procedures and surgery are the most common management modalities, but medical therapy can also play a significant role in preventing or delaying recurrence. In this review, we describe the morphology, pathophysiology, clinical presentation, evaluation, management, and prognosis of iSGS.

Suture fixation of tracheal stents for the treatment of upper trachea stenosis: a retrospective study

Background

Stent migration is a common complication in treating trachea stenosis. There is no report concerning suture fixation of tracheal stent. The aim of this study was to investigate whether suture fixation of tracheal stent could avoid stent migration in patients with upper trachea stenosis. The complications were further investigated.

Methods

The patients with upper trachea stenosis who underwent tracheal stent placement for benign/malignant conditions in our hospital between May 2016 and April 2018 were retrospectively reviewed. Clinical data were collected for each patient, including age, gender, co-morbid diseases, site of tracheal obstruction, degree of tracheal obstruction, success of stent placement, impact on patient’s symptoms, complications, etc.

Results

Eleven patients (8 males and 3 females; range of age: 17–85, and average age of 63) were enrolled into this study. Six silicone stents and five membrane-covered metal stents were used. The surgery was successfully performed in all the cases. The postoperative recovery was uneventful. All symptoms of the patients were relieved. No complications occurred. The average follow-up for patients was 5 months (range of 1–13 months). During the follow-up, no stent migration was observed according to CT and bronchoscope.

Conclusion

The results suggested that suture fixation of stents could avoid stent migration in treating upper trachea stenosis with metal stent or silicone stent. This method seemed to be effective without operation complications.

Experience with Transcordal Silicone Stents in Adult Laryngotracheal Stenosis: A Bicentric Retrospective Study

BACKGROUND

Benign stenosis involving laryngeal and upper tracheal structures represents a therapeutic challenge. Open surgery and endoscopic management have to be discussed by a multidisciplinary board in order to evaluate the risk and benefit for each patient.

OBJECTIVE

The objective of this retrospective study was to report the experience of two French centers with transcordal silicone stents (TSS) in the endoscopic management of benign laryngotracheal stenosis (BLTS) in adults, with focus on efficacy, safety, and tolerability.

METHODS

We performed a retrospective chart review of all cases of BLTS treated with TSS between January 2001 and June 2017 at two tertiary centers in France: the Centre Hospitalier Régional Universitaire de Strasbourg and the Hôpital Nord de Marseille.

RESULTS

A total of 17 patients were included. Eleven had a tracheostomy at initial management which consisted of 8 T-tubes and 9 strictly endoluminal stents placements. The main complications were minor aspirations in 5 patients (29%), granulation in 3 patients (18%), migration in 2 patients (12%), and severe dysphonia in 3 patients (18%). After a mean duration of 18.3 months, 11 patients (65%) had had their TSS definitely removed, 13 patients were tracheostomy free (76%), and a TSS remained in place in 4 patients (24%).

CONCLUSIONS

Adult BLTS treatment with TSS placement is associated with low morbidity and excellent clinical outcomes, with a large proportion of patients free of airway instrumentation on long-term follow-up.

A novel simple external fixation for securing silicone stent in patients with upper tracheal stenosis

Upper tracheal stenosis is considered as a potentially life-threatening condition. Silicone stenting is an attractive treatment option for patients with upper tracheal stenosis. However, its use has been compromised by a major complication, stent migration. In the report, we introduced a novel external fixation of silicone stent which only needed one puncture site and involved a silicon chip as an anchoring device. All equipment and materials including the silicon chip were available in routine bronchoscopy suite. The method had been successfully performed in three patients with upper tracheal stenosis at our institution. And the patients were monitored for over 20 months after the intervention, and no spontaneous stent migration occurred. Therefore, we believe this is a simple and reliable approach for improving the outcome of silicone stenting in patients with upper tracheal stenosis and should be introduced in clinical practice.

Clinical implications of differentiating between types of post-tracheostomy tracheal stenosis

Background

Post-tracheostomy tracheal stenosis (PTTS) can be divided into four types according to stenosis mechanism and site: subglottic, stoma, cuff, and tip granuloma. However, there is little information available regarding clinical differences among types of PTTS; therefore, we evaluated the clinical differences between these types.

Methods

We retrospectively evaluated 99 PTTS patients who underwent interventional bronchoscopy between 2004 and 2014. Patients were divided into two groups according to pathophysiological similarities as follows: subglottic or stoma type (n=59) and cuff or tip type (n=40).

Results

There were no differences in baseline characteristics between groups. However, silicone stents were more frequently needed in patients with subglottic or stoma type stenosis (76%) than those with cuff or tip type stenosis (55%, P=0.031) to maintain airway patency. On the contrary, permanent tracheostomy was more frequently performed in patients with cuff or tip type stenosis (50%) than those with subglottic or stoma type stenosis (19%, P=0.002). Finally, successful removal of the tracheostomy tube without surgery and procedure- or disease-related mortality were more frequently achieved in patients with subglottic or stoma type stenosis (71%) than those with cuff or tip type stenosis (45%, P=0.012).

Conclusions

Although there were no significant differences in baseline characteristics between PTTS types, patients with subglottic or stoma type stenosis had more favorable outcomes than those with cuff or tip type stenosis. Therefore, it could be important to distinguish between types of PTTS when assessing prognosis.

Transtracheal single-point stent fixation in posttracheotomy tracheomalacia under cone-beam computer tomography guidance by transmural suturing with the Berci needle - a perspective on a new tool to avoid stent migration of Dumon stents

Tracheomalacia or tracheobronchomalacia (TM or TBM) is a common problem especially for elderly patients often unfit for surgical techniques. Several surgical or minimally invasive techniques have already been described. Stenting is one option but in general long-time stenting is accompanied by a high complication rate. Stent removal is more difficult in case of self-expandable nitinol stents or metallic stents in general in comparison to silicone stents. The main disadvantage of silicone stents in comparison to uncovered metallic stents is migration and plugging. We compared the operation time and in particular the duration of a sufficient Dumon stent fixation with different techniques in a patient with severe posttracheotomy TM and strongly reduced mobility of the vocal cords due to Parkinson’s disease. The combined approach with simultaneous Dumon stenting and endoluminal transtracheal externalized suture under cone-beam computer tomography guidance with the Berci needle was by far the fastest approach compared to a (not performed) surgical intervention, or even purely endoluminal suturing through the rigid bronchoscope. The duration of the endoluminal transtracheal externalized suture was between 5 minutes and 9 minutes with the Berci needle; the pure endoluminal approach needed 51 minutes. The alternative of tracheobronchoplasty was refused by the patient. In general, 180 minutes for this surgical approach is calculated. The costs of the different approaches are supposed to vary widely due to the fact that in Germany 1 minute in an operation room costs on average approximately 50–60€ inclusive of taxes. In our own hospital (tertiary level), it is nearly 30€ per minute in an operation room for a surgical approach. Calculating an additional 15 minutes for patient preparation and transfer to wake-up room, therefore a total duration inside the investigation room of 30 minutes, the cost per flexible bronchoscopy is per minute on average less than 6€. Although the Dumon stenting requires a set-up with more expensive anesthesiology accompaniment, which takes longer than a flexible investigation estimated at 1 hour in an operation room, still without calculation of the costs of the materials and specialized staff that the surgical approach would consume at least 3,000€ more than a minimally invasive approach performed with the Berci needle. This difference is due to the longer time of the surgical intervention which is calculated at approximately 180 minutes in comparison to the achieved non-surgical approach of 60 minutes in the operation suite.

Indications and interventional options for non-resectable tracheal stenosis

Non-specific presentation and normal examination findings in early disease often result in tracheal obstruction being overlooked as a diagnosis until patients present acutely. Once diagnosed, surgical options should be considered, but often patient co-morbidity necessitates other interventional options. Non-resectable tracheal stenosis can be successfully managed by interventional bronchoscopy, with therapeutic options including airway dilatation, local tissue destruction and airway stenting. There are common aspects to the management of tracheal obstruction, tracheomalacia and tracheal fistulae. This paper reviews the pathogenesis, presentation, investigation and management of tracheal disease, with a focus on tracheal obstruction and the role of endotracheal intervention in management.

Novel use of a percutaneous endoscopic gastrostomy tube fastener for securing silicone tracheal stents in patients with benign proximal airway obstruction

BACKGROUND

Benign tracheal obstruction occurs for a variety of reasons. Bronchoscopic intervention includes silicone stent placement, which effectively maintains airway patency. Stent migration is a common complication, particularly when placed in the proximal trachea. We used a novel technique of securing tracheal stents with a percutaneous endoscopic gastrostomy tube fastener (PEG-TF) to prevent stent migration. The purpose of this study was to determine the feasibility of securing silicone stents in the proximal trachea with PEG-TF.

METHODS

Silicone stents were placed under general anesthesia by rigid bronchoscopy in 7 consecutive patients with inoperable benign proximal tracheal obstruction. PEG-TFs were placed under sterile conditions with direct bronchoscopic visualization. A needle was inserted through the anterior neck and silicone stent wall allowing stylet introduction of a T-fastener into the interior of the stent. The T-fastener was secured externally by a metal clamp and cotton pledget at the surface of the neck. Patients had routine outpatient follow-up and covered the external portion of the PEG-TF with a waterproof dressing when showering.

RESULTS

All 7 PEG-TFs were placed without complications. The PEG-TFs were left in for 1 to 25 weeks. Complications of the PEG-TF included localized cellulitis and suture breakage. No stent migration occurred while the fastener was in place. Two stents were removed within 2 weeks due to patient's difficulty tolerating the stent.

CONCLUSIONS

Securing silicone stents in the proximal trachea is feasible and may prevent stent migration, but further study and possible modification of the PEG-TF device are needed.

External fixation of proximal tracheal airway stents: a modified technique

Treatment of subglottic and proximal tracheal stenosis for nonsurgical candidates includes tracheostomy, Montgomery T tubes, and silicone stents. When used in lesions with concomitant malacia, silicone stents have a high incidence of migration. We describe a simple and effective technique of securing endoluminal stents using an Endo Close suturing device (Coviden, Boston, MA) and an external silicone button in 9 consecutive patients.

Tracheal stricture and fistula: management with a barbed silicone-covered retrievable expandable nitinol stent

OBJECTIVE

The purpose of this study was to evaluate the safety and effectiveness of a barbed silicone-covered retrievable expandable nitinol stent in preventing stent migration in patients with tracheal strictures or fistulas.

SUBJECTS AND METHODS

Under fluoroscopic guidance, barbed silicone-covered retrievable expandable nitinol stents were placed in 15 patients with tracheal strictures, two patients with fistulas, two patients with combined strictures and fistulas, and one patient with variable extrathoracic airway obstruction. The three pairs of barbs were attached to the external stent surface at the middle of the stent at equal intervals. Technical success, improvement in respiratory status, complications, and related interventions were evaluated.

RESULTS

The technical success rate was 100%, and respiratory status improved or the fistula closed in all 20 patients. Complications included sputum retention (three patients), tumor overgrowth (three patients), pain (one patient), and granulation tissue formation (one patient). No stent migration occurred, even in the three patients without fixed strictures. Four stents subsequently were removed because of complications, and one stent was removed because the patient's condition improved. Stent removal was not difficult and was uneventful. The silicone membranes and barbs of the removed stents were intact.

CONCLUSION

Use of a barbed silicone-covered retrievable expandable nitinol stent relieves dyspnea and facilitates fistula closure in patients with benign or malignant tracheal strictures or fistulas. The barbed design of the stent is important in preventing migration.