Long-Term Preclinical Evaluation of a Permanent Stent Developed for the Human Eustachian Tube

The Eustachian tube (ET) is a bottleneck when it comes to middle ear (ME) health. If its function is impaired, this can lead to serious consequences for the patient, such as hearing problems or deafness. Therefore, this study investigated a tapered nitinol stent (3-5 mm × 14 mm) for the human ET as a potential new permanent treatment for chronic Eustachian tube dysfunction (ETD) and thus ME ventilation disorders. The self-expanding stent was inserted unilaterally into the ET of 24 sheep with observation periods of 3, 6, and 12 months. Local tissue effects and the safety of the stent insertion were analyzed based on regular endoscopic checks, weekly tympanometry measurements, final imaging, and histological examinations. The animals showed no stent-related health restrictions. However, the individual anatomy and stenting procedure had an influence on the results. The tissue reaction in the endoscopic examinations was mild even though no concomitant antibiotics were administered. After all three monitoring periods, stented ETs had a significantly larger ET lumen than the non-stented contralateral ETs. However, tissue growth was detected in the stent. Overall, the first long-term study on an ET stent showed that the tapered ET stent could be a promising treatment option for ETD.

Degrees of Inflammation in the Treatment of Subglottic Stenosis in a Rabbit Model: Histopathological Assessment of a Novel Bioabsorbable Ultra-high Ductility Magnesium Alloy Stent

OBJECTIVE

Utilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent.

METHODS

SGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers.

RESULTS

We found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area.

DISCUSSION

Rabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS.

Tracheobronchial stents: an expanding prospect

The first dedicated tracheobronchial silicone stent was designed by the French pulmonologist Jean-Paul Dumon. The most common indications for stenting are to minimise extrinsic airway compression from mass effect, maintain airway patency due to intrinsic obstruction or treat significant nonmalignant airway narrowing or fistulae. Silicone stents require rigid bronchoscopy for insertion; however, they are more readily repositioned and removed compared with metallic stents. Metallic stents demonstrate luminal narrowing when loads are applied to their ends, therefore stents should either be reinforced at the ends or exceed the area of stenosis by a minimum of 5 mm. Nitinol, a nickel-titanium metal alloy, is currently the preferred material used for airway stents. Airway stenting provides effective palliation for patients with severe symptomatic obstruction. Drug-eluting and three-dimensional printing of airway stents present promising solutions to the challenges of the physical and anatomical constraints of the tracheobronchial tree. Biodegradable stents could also be a solution for the treatment of nonmalignant airway obstruction.

Single-center review on safety of biodegradable airway stenting in pediatric population

BACKGROUND

Tracheobronchomalacia (TBM) and airway stenosis are recognized etiologies of airway obstruction among children. Their management is often challenging, requiring multiple interventions and prolonged respiratory support with associated long-term morbidity. Metallic or silicone stents have been used with mixed success and high complication rates. More recently biodegradable Ella stents (BES) provided an attractive interventional option.

OBJECTIVES

We report our experience in the treatment of TBM and vascular airway compression using BES. We deliberately downsized them to minimize intraluminal granulation tissue formation.

MATERIALS AND METHODS

Retrospective study over an 8-year period between November 2012 and December 2020 of pediatric patients with severe airway obstruction requiring airway stenting for extubation failure, malacic death spells, recurrent chest infections, or lung collapse.

RESULTS

Thirty-three patients (5 tracheal and 28 bronchial diseases) required 55 BES during the study period. The smallest patient weighed 1.8 kg. Median age of patient at first stent implantation was 13.1 months (IQR 4.9-58.3). The majority of the bronchial stents were in the left main bronchus (93%), of which 57% for vascular compression. Repeat stents were used in 19 patients (57.7%), with a range of two to four times. We did not experience erosion, infection, or obstructive granuloma needing removal by forceps or lasering. Three stent grid occluded with secretions needing bronchoscopic lavage. Stent migration occurred in three patients.

CONCLUSIONS

BES holds promise as a treatment option with low rate of adverse effects for a specific subset of pediatric patients with airway malacia or vascular compression. Further studies are warranted.

Bronchial Remodeling Following Airway Stenting in Pediatric Patients With Tracheobronchial and Congenital Heart Disease

Background

Treatment of tracheobronchial disease in medically complex infants with congenital heart disease (CHD) is often challenging. When conservative management or surgery fails or is contraindicated, airway stenting can allow for advancement of care or weaning of respiratory support.

Methods

We identified 8 cases of airway stenting with balloon-expandable coronary bare-metal stents performed at our institution between February 2019 and September 2022 to relieve conservative treatment-refractory tracheobronchial disease in pediatric patients with CHD. All patients underwent rigid microlaryngoscopy, bronchoscopy, and flexible bronchoscopy as well as computed tomography angiography.

Results

Eight patients underwent technically uncomplicated placement of balloon-expandable coronary bare-metal stents in the trachea or bronchus. Immediate improvement in respiratory parameters was noted following stent placement. Six patients were able to wean mechanical ventilation following stent placement, with a median of 2.5 days of mechanical ventilation following the procedure (range, 0-219). All stents were subsequently endoscopically removed at a median of 6.8 months (range, 0.4-16.3 months). In 6 patients, bronchoscopy after stent removal demonstrated a rounder configuration of the airway consistent with bronchial remodeling.

Conclusions

In pediatric patients with tracheobronchial and CHD, airway stenting with balloon-expandable bare-metal coronary stents relieved respiratory symptoms with minimal complications and resulted in bronchial remodeling after stent removal.

Surgical Management of 48 Patients with Retrosternal Goiter and Tracheal Stenosis: A Retrospective Clinical Study from a Single Surgical Center

Background

Benign retrosternal thyroid goiters can become large enough to compress the trachea and result in tracheomalacia and stenosis. This retrospective study from a single surgical center aimed to study the surgical management of 48 patients with retrosternal goiter and tracheal stenosis diagnosed and treated from January 2017 to December 2021.

Material/Methods

All preoperative contrast-enhanced CT scans showed retrosternal goiter and tracheal stenosis. RG was classified into type I in 28 patients, type II in 12 patients, and type III in 8 patients. TS was classified into grade I in 31 patients, grade II in 11 patients, and grade III in 6 patients. All patients were referred for surgery. Clinicopathologic features and surgical outcomes were recorded.

Results

All operations were successfully performed. There were 41 patients with transcervical incision, 4 with cervical incision+sternotomy, 2 with cervical incision and thoracoscopic surgery, and 1 with cervical incision and surgery via the subxiphoid approach. Two patients presented recurrent laryngeal nerve injury. One patient showed short-term hand and foot numbness. The patients were pathologically diagnosed as simple nodular goiter (n=27), nodular goiter combined with cystic change (n=6), adenomatous nodular goiter (n=10), and thyroid adenoma (n=5). There was no prominent tumor recurrence or gradual TS remission.

Conclusions

This study has highlighted that patients with retrosternal goiter and tracheal stenosis may have comorbidities and require a multidisciplinary approach to management. The choice of anesthesia, surgical approach, and maintenance of the airway during and after surgery should be individualized.

Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases

The management of tracheal wall lacerations is debated. Current treatments are mainly derived by the experience on adults and include conservative or surgical treatments depending on the clinical condition of the patient. We report our preliminary data with removable tracheal stents in 3 children with tracheal tears and respiratory failure. If performed in specialized centers with appropriate endoscopic and clinical follow-up, airway stents can be considered a valid and safe conservative treatment for tracheal tears and an alternative to intubation or tracheostomy. Further studies are needed to compare different therapeutic options and better define the management and duration of stent treatment.

Histological and structural effects of biodegradable polydioxanone stents in the rabbit trachea

OBJECTIVES

The aim of this study was to evaluate the potential biologic effects caused by successive placement of biodegradable polydioxanone (PDO) stents in the rabbit trachea. PDO stents could eventually induce a fibroproliferative reaction in the submucosa that could be beneficial in the treatment of malacia due to an increase in its consistency without impairing the tracheal lumen.

METHODS

Sixteen adult NZ rabbits were distributed into 3 groups with different survival times according to the number of stents placed: One stent (14 weeks), 2 stents (28 w.), and 3 stents (42 w.). Stent insertion was performed endoscopically in the cervical trachea of the animal. Histopathological studies included Masson's trichrome staining for submucosal fibrosis and Safranin O to assess structural integrity of cartilage. Potential inflammatory changes were analysed by means of immunohistochemistry determining the number of CD45 positive cells.

RESULTS

Stent placement was successful in every case. Histological studies did not show a statistically significant increase in tracheal wall collagen area and cartilage structure was not modified in those rabbits with one or more PDO stents inserted compared to non-stented tracheal sections. Furthermore, no statistically significant changes in the number of CD45+ cells were observed in stented tracheal segments compared to normal tracheal tissues.

CONCLUSIONS

According to our data, successive PDO stenting caused mild inflammatory changes in the tracheal wall, no increase in the collagen matrix, and the cartilaginous support was not modified during a long follow-up period (up to 42 weeks). These findings suggest that they may be safe and show good biocompatibility in the long-term.

Long-term outcomes in children undergoing vascular ring division: a multi-institution experience

 

OBJECTIVES

Vascular rings are rare anomalies of congenital heart disease that cause respiratory and gastrointestinal symptoms. This study assessed the long-term outcomes of patients with vascular ring division.

METHODS

A multi-institution retrospective review of 371 patients with vascular rings undergoing surgical division at 3 paediatric cardiac institutions between November 2007 and October 2019 was performed.

RESULTS

The complete vascular rings consisted of a double aortic arch (24.5%), right aortic arch with left ligamentum arteriosum (36.7%) and left aortic arch, with right ligamentum arteriosum (0.5%). The incomplete vascular rings consisted of a pulmonary artery sling (22.9%), left aortic arch with aberrant right subclavian artery (15.1%) and innominate artery compression syndrome (0.3%). Respiratory symptoms included stridor (71.4%), wheezing (49.1%), coughing (31.5%), gastrointestinal symptoms included choking (12.4%), dysphagia (3.2%) and emesis (1.9%). Only one patient died after discharge, yielding a late mortality rate of 0.3% (1/360). The 10-year overall survival rate was 96.8%. Postoperative complications were reported in 51 patients, 15 of whom required reoperation. The 10-year freedom from reoperation rate was 95.9%. Follow-up was completed in 95.4% (354/371) of patients, with a mean follow-up time of 4.3 ± 2.9 years (range from 1 to 13 years). Twenty patients (5.6%) experienced residual symptoms during long-term follow-up.

CONCLUSIONS

The outcomes of vascular ring division are excellent. A Kommerell diverticulum >1.5 times the aberrant left subclavian artery origin is an operative indication for primary resection. Tracheomalacia is a risk factor for reoperation and residual symptoms, and preoperative fibrobronchoscopy is important for evaluation.

Patterned Drug-Eluting Coatings for Tracheal Stents Based on PLA, PLGA, and PCL for the Granulation Formation Reduction: In Vivo Studies

Expandable metallic stent placement is often the only way to treat airway obstructions. Such treatment with an uncoated stent causes granulation proliferation and subsequent restenosis, resulting in the procedure’s adverse complications. Systemic administration of steroids drugs in high dosages slows down granulation tissue overgrowth but leads to long-term side effects. Drug-eluting coatings have been used widely in cardiology for many years to suppress local granulation and reduce the organism’s systemic load. Still, so far, there are no available analogs for the trachea. Here, we demonstrate that PLA-, PCL- and PLGA-based films with arrays of microchambers to accommodate therapeutic substances can be used as a drug-eluting coating through securely fixing on the surface of an expandable nitinol stent. PCL and PLA were most resistant to mechanical damage associated with packing in delivery devices and making it possible to keep high-molecular-weight cargo. Low-molecular-weight methylprednisolone sodium succinate is poorly retained in PCL- and PLGA-based microchambers after immersion in deionized water (only 9.5% and 15.7% are left, respectively). In comparison, PLA-based microchambers retain 96.3% after the same procedure. In vivo studies on rabbits have shown that effective granulation tissue suppression is achieved when PLA and PLGA are used for coatings. PLGA-based microchamber coating almost completely degrades in 10 days in the trachea, while PLA-based microchamber films partially preserve their structure. The PCL-based film coating is most stable over time, which probably causes blocking the outflow of fluid from the tracheal mucosa and the aggravation of the inflammatory process against the background of low drug concentration. Combination and variability of polymers in the fabrication of films with microchambers to retain therapeutic compounds are suggested as a novel type of drug-eluting coating.

Pediatric Airway Endoscopy: Recommendations of the Society for Pediatric Pneumology

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

Resorbable airway splint, stents, and 3D reconstruction and printing of the airway in tracheobronchomalacia

Tracheobronchomalacia (TBM) is the most common tracheobronchial obstruction. Most cases are mild to moderate; therefore, they do not need surgical treatment. Severe tracheomalacia, however, represents a diagnostic and therapeutic challenge since they are very heterogeneous. In the armamentarium of resources for the treatment of dynamic airway collapse, splints and stents are two underused strategies and yet, they may represent the best alternative in selected cases. Lately, computed tomography 3D reconstruction of the airway has been used for the design of virtual models that can be 3D-printed for the creation of novel devices to address training, simulation, and biotechnological implants for refractory and severe airway malformations. This manuscript examines the role of resorbable stents, splints, and the 3D reconstruction and printing of the pediatric airway in tracheobronchomalacia.

Congenital airway anomalies

Congenital airway anomalies (CAA) include a variety of conditions that cause respiratory distress in neonates and infants. These malformations occur at various anatomic levels and manifest in a wide spectrum of airway symptoms, with presentation significantly influenced by the level at which obstruction occurs as well as by the severity of obstruction. The prevalence of congenital airway malformations has been estimated to range between 0.2 and 1 in 10,000 live births. The most frequent CAA are laryngomalacia, bilateral vocal cord paralysis, subglottic stenosis, laryngeal webs, subglottic hemangioma, tracheomalacia, congenital tracheal stenosis, laryngotracheal cleft, and tracheal agenesis.

Pediatric bronchoscopy: recent advances and clinical challenges

Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.

The role of bioresorbable intraluminal airway stents in pediatric tracheobronchial obstruction: A systematic review

INTRODUCTION

Tracheal stenosis and tracheobronchomalacia are complicated, patient-specific diseases that can be treated with intraluminal stenting. Most commonly, silicone and metal stents are utilized, however, they pose significant early and late morbidity and are further complicated by growth of the airway in the pediatric population. Given recent improvements in materials science, there is a growing body of evidence suggesting a strong role for bioresorbable intraluminal stents in treating pediatric tracheobronchial obstruction.

METHODS

A PubMed.gov literature search was performed on December 3, 2019 and May 15, 2020, and a 2-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((((bioresorbable) OR bioabsorbable) OR resorbable) OR absorbable) OR biodegradable AND airway) OR trachea) AND stent. A pooled statistical analysis was performed on all reported pediatric patients using SPSS software.

RESULTS

1369 publications were screened and 26 articles with original data were identified. Materials used included polydioxanone (PDO), poly-l-lactic acid (PLLA), polyglycolic acid/poly-l-lactide co-polymer with Proglactin 910 (Vicryl®-PDS®), polycaprolactone (PCL), magnesium alloys, and co-polymers in varying proportions. Twelve articles presented data on human subjects, 8 of which were case series and case reports on pediatric populations using polydioxanone (PDO) stents. Pooled statistical analysis demonstrated an average age of 19 months (range 0.25-144), 56.5% associated with a cardiovascular anomaly, and overall complication rate of 21.7%, with a stent fragment foreign body being the most common (8.7%), followed by significant granulation tissue (4.3%), stent migration (4.3%), and local stenosis (4.3%). Comparative analysis demonstrated short-term improvement (up to 1 month) has a statistically significant association with tracheobronchomalacia versus tracheal stenosis on chi-squared test (p = 0.001). The remaining analyses did not yield statistical significance.

CONCLUSION

The reported application of bioresorbable materials as intraluminal airway stents is positive. All comparative animal studies report biocompatibility and fewer morbidities compared to metal and silicone stents, however, in human studies there are concerns over the short interval of degradation and the potential for obstructive foreign bodies in poorly seated stents. Overall, there are clear, reproducible advantages to bioresorbable intraluminal stents in pediatric airway obstruction, as well as common pitfalls, that warrant further research.

Congenital malformations potentially affecting respiratory function: multidisciplinary approach and follow-up

Background and aim.

Congenital malformations such as oesophageal atresia (OA) and tracheoesophageal fistula (TOF), congenital pulmonary airway malformations (CPAMs), congenital diaphragmatic hernia (CDH) and vascular rings (VRs) can affect lung development and respiratory function. This observational study describes our multidisciplinary approach and respiratory follow-up of children with such congenital malformations.

Methods.

Clinical data of children followed at the Pediatric Respiratory Unit of Parma University Hospital (Italy) between January 2015 and January 2020 were collected.

Results.

Twenty-three patients with congenital malformation affecting lung development were identified. Almost half of our patients were diagnosed with fetal ultrasound. Children attended the clinic at a mean age of 3 (3.7) years and follow-up visits were scheduled every 6 months average. More than half of our patients were hospitalized for lower respiratory tract infections. Six out of 9 children able to perform spirometry showed anomalies in lung function. Chest physiotherapy was recommended especially in children with OA.

Conclusions.

Children with congenital malformations affecting lung development are at risk of short and long-term respiratory complications, especially in the first years of life. OA was the malformation more associated to respiratory problems. Multidisciplinary approach and appropriate personalized follow-up are recommended for the best management of these children. (www.actabiomedica.it)

Clinical outcomes of self-expandable metallic stents for malignant obstructive atelectasis

Self-expandable metallic stents (SEMSs) have been widely used in the treatment of malignant central airway obstruction. However, few reports focus on the treatment of atelectasis and how to estimate the prior probability of success via SEMSs placement, This current study aimed to study the safety and effectiveness of SEMSs for the treatment of obstructive atelectasis, and the value of preoperative CT enhancement for ventilation of atelectasis via SEMSs placement. A total of 35 patients with obstructive atelectasis (29 male and 6 female) was included from February 2012 to March 2018. The procedures were performed under fluoroscopic guidance, and bronchoscopic laser resection was performed for severe restenosis cases after SEMSs placement. Clinical and functional pulmonary data were recorded before and 3 months after the procedure. Follow-up involved clinical data and radiographic techniques at 48 h and at 1-, 3-, 6-, and 12-month intervals. Thirty-eight SEMSs were successfully implanted in 34 patients, included 29 Y type tracheal stents, 4 small y stents, and 5 straight airway stents. After stenting, 26 cases showed full ventilation, and 3 cases were partially ventilated. The technical success and clinical success was 97.1% and 82.9%, respectively. A higher maximum enhancement CT value was found in patients with full ventilation. Mean follow-up time was 18.8 ± 4.0 months. Eight cases showed restenosis and received endoscopic laser resection, included 1 case underwent removal and 3 cases received second stenting. There were 2 cases of perioperative non-operative death, and 11 cases of post-discharge death (2 cardiac deaths and 9 malignant tumors). The survival rates of 3 months, 1 year and 2 years were 78.6%, 58.5% and 58.5%, respectively. In conclusion, SEMSs placement is safe and effective for obstructive atelectasis, and the preoperative CT enhancement played an important role in estimating the prior probability of success in the treatment of atelectasis via SEMSs placement.

A combination of tracheoplasty and tracheal stenting is an acceptable method of treating severe congenital tracheobronchial stenosis under extracorporeal membrane oxygenation

BACKGROUND

Congenital tracheobronchial stenosis (CTBS) is a rare congenital condition characterized by complete cartilage rings covering varying lengths of the major airway. In this study, we reviewed the outcomes of patients with CTBS receiving surgical tracheoplasty in our institute.

METHODS

We retrospectively analyzed the outcomes of consecutive patients with CTBS operated between 2006 and 2017 when extracorporeal membrane oxygenation (ECMO) was used perioperatively.

RESULTS

In total, 11 patients (median follow-up period, 4.2 years; interquartile range, 1.6-5.4) were included. Seven were symptomatic in the neonatal period, 10 had cardiorespiratory anomalies, 7 required preoperative bronchoscopic balloon dilatation, and 1 required preoperative stent placement. Slide tracheoplasty (STP) was performed in 9 patients, and 2 underwent pericardial patch tracheoplasty. Seven patients required postoperative balloon dilatation, and 6 required postoperative stent placement. Early stenting provided immediate ventilatory improvement in all patients and facilitated successful extubation in a median of 4 days after stenting in 80% of the patients.

CONCLUSIONS

Under ECMO, severe CTBS could be successfully treated through a combination of tracheoplasty and bronchoscopic management. STP provided excellent results for solitary trachea stenosis with a minimum diameter of ≥3 mm. In selected patients, postoperative tracheobronchial stent placement was crucial in minimizing the ECMO duration and facilitating extubation.

LEVEL OF EVIDENCE

IV.

ERS statement on tracheomalacia and bronchomalacia in children

Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.

The suction-assisted endoscopic suture technique: A simple method for endotracheal suturing

BACKGROUND

Silicone stents are commonly employed to treat subglottic stenosis. A frequent complication is the tendency of stents to migrate. As such, various techniques to secure stents have been developed over the years, none of which have gained large popularity. We present a novel, low-cost, and easy-to-perform technique herein.

OBJECTIVES

To describe a novel surgical technique to secure silicone stents and prevent migration for management of subglottic stenosis.

MATERIALS AND METHODS

After standard excision and dilation of stenotic portions in the subglottic or trachea. A silicone stent is introduced in a standard fashion. To secure the stent, an 18-G needle loaded with braided suture is inserted through skin, trachea, and stent. Endoscopic visualization then permits the surgeon to grasp the suture with forceps. A separate transcutaneous puncture site is performed with an 18-G needle attached to a 10-cc syringe (plunger removed) and blue tip suction within the empty syringe, creating an airtight suctioning tool. The grasped suture is gently introduced into the eye of the needle and quickly travels into the 10-cc syringe with suction assist, leaving both extracorporeal ends of the suture to tie.

RESULTS

This stitch has been employed on seven occasions on four patients. There have been no episodes of stent migration. A laboratory model found the 18-G needle and braided 3-0 suture performed optimally.

CONCLUSIONS

We present a novel surgical technique to secure silicone stents in management subglottic or tracheal stenosis.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 130:E346-E348, 2020.

3D-printed, externally-implanted, bioresorbable airway splints for severe tracheobronchomalacia

OBJECTIVES/HYPOTHESIS

To report the clinical safety and efficacy of three-dimensional (3D)-printed, patient-specific, bioresorbable airway splints in a cohort of critically ill children with severe tracheobronchomalacia.

STUDY DESIGN

Case series.

METHODS

From 2012 to 2018, 15 subjects received 29 splints on their trachea, right and/or left mainstem bronchi. The median age at implantation was 8 months (range, 3-25 months). Nine children were female. Five subjects had a history of extracorporeal membrane oxygenation (ECMO), and 11 required continuous sedation, six of whom required paralytics to maintain adequate ventilation. Thirteen were chronically hospitalized, unable to be discharged, and seven were hospitalized their entire lives. At the time of splint implantation, one subject required ECMO, one required positive airway pressure, and 13 subjects were tracheostomy and ventilator dependent, requiring a median positive end-expiratory pressure (PEEP) of 14 cm H₂ O (range, 6-20 cm H₂ 0). Outcomes collected included level of respiratory support, disposition, and splint-related complications.

RESULTS

At the time of discharge from our institution, at a median of 28 days postimplantation (range, 10-56 days), the subject on ECMO was weaned from extracorporeal support, and the subjects who were ventilated via tracheostomy had a median change in PEEP (discharge-baseline) of -2.5 cm H₂ O (range, -15 to 2 cm H₂ O, P = .022). At median follow-up of 8.5 months (range, 0.3-77 months), all but one of the 12 surviving subjects lives at home. Of the 11 survivors who were tracheostomy dependent preoperatively, one is decannulated, one uses a speaking valve, six use a ventilator exclusively at night, and three remain ventilator dependent.

CONCLUSIONS

This case series demonstrates the initial clinical efficacy of the 3D-printed bioresorbable airway splint device in a cohort of critically ill children with severe tracheobronchomalacia.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1763-1771, 2019.

Long-term follow-up of self-expandable metallic stents in benign tracheobronchial stenosis: a retrospective study

BACKGROUND

Self-expandable metallic stents (SEMSs) have enabled a approving management of malignant airway stenosis. However, the long-term efficacy and safety of this treatment in patients with benign airway stricture are unclear. We conducted this study to retrospectively determine the efficacy and long-term outcomes in patients who have undergone SEMS placement for benign tracheobronchial stenosis.

METHODS

All patients treated with SEMSs from July 2003 to June 2016 were reviewed for symptomatic response, complications, and long-term outcomes.

RESULTS

Total 131 stents were successfully deployed in 116 patients. Ninety-eight patients demonstrated clinical improvement after stent insertion (84.48%; 95% confidence interval [CI]: 77.89-91.07). Compared with uncovered stents, covered stents were associated with more sore throats complaints or chest pain (13.89% versus 28.81%, P = 0.036) and with higher incidences of major and minor granulation tissue formation and with recurrent stenosis (4.17% versus 15.25%, P = 0.029; 11.11% versus 37.29%, P < 0.0001 and 9.72% versus 28.81%, P = 0.005, respectively). Each covered and uncovered stent developing tissue hyperplasia required a median of 2 (range: 1-15) and 1(range: 1-7) fibrobronchoscope with electrocautery therapy, respectively. At follow-up (median: 1276 days; range: 2-4263), 68 patients had complete resolution, 15 remained under interventional treatment, 8 had bronchial occlusions, 7 underwent surgery, 14 were lost to follow-up, and 4 died of stent unrelated causes.

CONCLUSION

SEMS placement achieved most clinical improvement among patients in our study, if adequate endotracheal measures were used to address stent-related complications. The use of permanent SEMSs for benign tracheobronchial stenosis was effective and safe for the majority of patients in a long-term follow-up.

TRIAL REGISTRATION

The study has been retrospectively registered in the China Clinical Trial Registry on October 21, 2018 (Registry ID: ChiCTR1800019024 ).

Outcome of long-term complications after permanent metallic left bronchial stenting in children

OBJECTIVES

We describe the way we treated 7 children with critical long-term complications after metallic balloon-expandable stenting in the left mainstem bronchus.

METHODS

Endoscopic follow-up included a first bronchoscopy 3 weeks after stenting, then monthly for 3 months, every 4-6 months up to 1 year and at scheduled times to calibrate stent diameter up to final calibration. When major complications occurred, patients underwent chest computed tomographic angiography.

RESULTS

In 1 of the 7 children (median age 2.8 years), metallic left bronchial stenting served as a bridge to surgery. After a median 4-year follow-up, all 7 children experienced recurrent stent ovalizations with stent breakage in 3 and erosion in 1. In 4 children, computed tomographic angiography showed abundant peribronchial fibrous tissue, in 2 left mediastinal rotation and in 1 displacement along the left bronchus after pulmonary re-expansion as the cause of stent-related complication. Of the 7 children, 6 underwent surgery (5 posterior aortopexy and 1 section of the ligamentum arteriosus) and 3 required nitinol stents placement within the metallic ones. One patient completed the follow-up, and 1 patient was lost to follow-up. All 5 remaining children still have permanent bronchial stents in place, patent and re-epithelialized after a median 10.5-year follow-up. There were no deaths.

CONCLUSIONS

Satisfactory anatomical relationships when children have stents placed in the left mainstem bronchus alone do not guarantee the final success. Several mechanisms intervene to cause critical stent-related complications in children during growth. Permanent metallic stents should be used carefully, and only in selected patients.

Congenital tracheal malformations

Congenital malformations of the trachea include a variety of conditions that cause respiratory distress in neonates and infants. A number of anomalies are self-limiting while others are life-threatening and require immediate therapy. The prevalence of congenital airway malformations has been estimated to range between 0.2 and 1 in 10,000 live births. The most frequent congenital tracheal malformations are: tracheomalacia, congenital tracheal stenosis, laryngotracheal cleft and tracheal agenesis. The management of congenital tracheal malformations is complex and requires an individualized approach delivered by a multidiscipilinary team within centralized units with the necessary expertise.

ERS statement: interventional bronchoscopy in children

Paediatric airway endoscopy is accepted as a diagnostic and therapeutic procedure, with an expanding number of indications and applications in children. The aim of this European Respiratory Society task force was to produce a statement on interventional bronchoscopy in children, describing the evidence available at present and current clinical practice, and identifying areas deserving further investigation. The multidisciplinary task force panel performed a systematic review of the literature, focusing on whole lung lavage, transbronchial and endobronchial biopsy, transbronchial needle aspiration with endobronchial ultrasound, foreign body extraction, balloon dilation and occlusion, laser-assisted procedures, usage of airway stents, microdebriders, cryotherapy, endoscopic intubation, application of drugs and other liquids, and caregiver perspectives. There is a scarcity of published evidence in this field, and in many cases the task force had to resort to the collective clinical experience of the committee to develop this statement. The highlighted gaps in knowledge underline the need for further research and serve as a call to paediatric bronchoscopists to work together in multicentre collaborations, for the benefit of children with airway disorders.

Temporary Tracheal Stenting After Pulmonary Artery Sling Repair in a Newborn

Pulmonary artery sling (PAS) is a rare disease frequently associated with severe malacia and stenosis of the trachea. We present a two-day-old newborn that underwent urgent surgery for PAS and needed prolonged respiratory support afterward. Temporary airway stenting above the level of the tracheal bifurcation was performed five days after surgery to overcome severe airway obstruction caused by tracheomalacia and laceration of the tracheal mucosa after diagnostic bronchoscopy. Two days after the procedure, the child could be extubated and after two weeks the stent was removed without complications. Temporary tracheal stenting after PAS repair can be an effective therapeutic strategy in newborns with tracheal obstruction and allows timely weaning from ventilator support.

Airway stenting in a child with spondyloepiphyseal dysplasia congenita: 13-Year survival

We describe the case of a boy with spondyloepiphyseal dysplasia congenita. At birth, he experienced severe respiratory distress necessitating tracheotomy. Endoscopy done because mechanical ventilation failed to resolve desaturations disclosed severe tracheo-bronchomalacia. A Polyflex silicone stent was placed in the trachea (replaced by Y-Dumon stent) and 2 Palmaz metallic stents in the mainstem bronchi (overlapped with 2 Jomed stents 5 years later). Airway stenting guaranteed a suitable respiratory status and allowed a child who was expected to die at birth, to reach 13.5 years old in good conditions.

Stents for airway strictures: selection and results

Airway stents can provide effective and timely relief in patients with central airway obstruction. Silicone based stents are the most commonly used airway stents worldwide with a long track record of safety. Metallic stents continue to evolve from the earliest uncovered versions to a variety of newly designed covered stents. Despite the availability of a variety of stent materials and designs, minimal advances have been made towards innovation in stent technology and an ideal stent has unfortunately not yet been developed. Nevertheless, the first generation of biodegradable airway stents are available, work on drug-eluted stents is in the pipeline and three-dimensional printing of a customized airway stent may be the future. In this review, we discuss selection and results for most commonly utilized airway stents.

Paclitaxel Drug-eluting Tracheal Stent Could Reduce Granulation Tissue Formation in a Canine Model

Background:

Currently available silicone and metallic stents for tracheal stenosis are associated with many problems. Granulation proliferation is one of the main complications. The present study aimed to evaluate the efficacy of paclitaxel drug-eluting tracheal stent in reducing granulation tissue formation in a canine model, as well as the pharmacokinetic features and safety profiles of the coated drug.

Methods:

Eight beagles were randomly divided into a control group (bare-metal stent group, n = 4) and an experimental group (paclitaxel-eluting stent group, n = 4). The observation period was 5 months. One beagle in both groups was sacrificed at the end of the 1^st and 3^rd months, respectively. The last two beagles in both groups were sacrificed at the end of 5^th month. The proliferation of granulation tissue and changes in tracheal mucosa were compared between the two groups. Blood routine and liver and kidney function were monitored to evaluate the safety of the paclitaxel-eluting stent. The elution method and high-performance liquid chromatography were used to characterize the rate of in vivo release of paclitaxel from the stent.

Results:

Compared with the control group, the proliferation of granulation tissue in the experimental group was significantly reduced. The drug release of paclitaxel-eluting stent was the fastest in the 1^st month after implantation (up to 70.9%). Then, the release slowed down gradually. By the 5^th month, the release reached up to 98.5%. During the observation period, a high concentration of the drug in the trachea (in the stented and adjacent unstented areas) and lung tissue was not noted, and the blood test showed no side effect.

Conclusions:

The paclitaxel-eluting stent could safely reduce the granulation tissue formation after stent implantation in vivo, suggesting that the paclitaxel-eluting tracheal stent might be considered for potential use in humans in the future.

Noteworthy Literature Published in 2016

This article is a review of the literature published during the 12 months of 2016 that are of interest to the congenital cardiac anesthesiologist. Five themes are addressed for 2016, and 53 peer-reviewed articles are discussed.

Biodegradable airway stents in infants - Potential life-threatening pitfalls

OBJECTIVE

The solution of severe tracheobronchial obstructions in early childhood means a great challenge. Biodegradable stents were intended to be a minimally invasive temporary solution which may decrease the number of interventions and limit the possible complications of stenting procedures. However, our first experiences have brought out a new, - especially in childhood - potentially life-threatening complication of this concept.

METHODS

Five SX-ELLA biodegradable polydioxanone stents was applied in three patients because of severe tracheobronchial obstruction: congenital tracheomalacia (7 day-old), acquired tracheomalacia (10 month-old), and congenital trachea-bronchomalacia (10 month-old).

RESULTS

The breathing of all children improved right after the procedure. We observed degradation of the stent from the 5th postoperative week which resulted in large intraluminar fragments causing significant airway obstruction: one patient died of severe pneumonia, the other baby required urgent bronchoscopy to remove the obstructing 'foreign body' from the trachea. In the third case repeated stent placements successfully maintained the tracheal lumen.

CONCLUSIONS

Polydioxanone stents may offer an alternative to metallic or silastic stents for collapse or external compression of the trachea in children; however, large decaying fragments mean a potential risk especially in the small size pediatric airway. The fragmentation of the stent, which generally starts in the 4-6 postoperative weeks, may create large sharp pieces. These may be anchored to the mucosa and covered by crust leading to obstruction. As repeated interventions are required, we do not consider the application of biodegradable stents unambiguously advantageous.

Biodegradable polydioxanone stent as a new treatment strategy for tracheal stenosis in a rabbit model

PURPOSE

Congenital tracheal stenosis (CTS) is a rare condition and difficult to treat. Slide tracheoplasty has unsatisfactory outcomes for severe neonatal symptomatic CTS. This study evaluated the use of biodegradable polydioxanone stents (BD stent) in a rabbit model of CTS.

METHODS

Tracheal stenosis was induced in female Japanese white rabbits, 9-10weeks old, by direct scraping of the tracheal mucosa with a nylon brush following transverse incision of the trachea (control group, n=4). Seven days later, we incised the trachea again and inserted a BD stent (15×5mm) into the trachea (stent group, n=4). Arterial blood gas analysis was performed twice weekly for 1month after the procedure.

RESULTS

In the control group, respiratory acidosis arising from ventilatory failure was observed on postoperative days 7-10. Rabbits were sacrificed at 11.5days after scraping. Severe tracheal stenosis resulting from inflammatory granulation was detected in the scraped region in all rabbits. In the stent group, arterial blood gas analysis was normal at 28days after stent insertion. The BD stent maintained patency of the tracheal lumen and prolonged survival for 1month.

CONCLUSIONS

The use of BD stent represents a promising new treatment method for tracheal stenosis.

Tracheobronchial stents in children

Tracheobronchial obstruction is infrequent in children and still remains a challenging matter of concern. Management alternatives vary from conservative treatment to complex surgical techniques or endoscopic interventional procedures. Airway stenting in children is relatively recent and follows the trail of the experience in adult patients. Nevertheless, there are basic differences between both age groups like the benign nature of most obstructions and the small size of the pediatric airway. These specific features raise the issues of the precise role of tracheobronchial stenting in children and the selection of the most adequate device. Stents fall into four main categories according to the material they are made of: metallic, plastic, hybrid, and biodegradable. Each type has its own advantages and drawbacks so the ideal stent is not yet available. Despite increasing experience with stenting, definite clinical criteria for their use in children are yet to be established. Even so, there seems to be a basic general agreement that stents may play a role in particular clinical settings in which there are no other therapeutic options.

Initial experience with a new biodegradable airway stent in children: Is this the stent we were waiting for?

OBJECTIVE

To report our experience with a new type of biodegradable airway stent in the setting of severe tracheobronchial obstruction in children.

DESIGN AND METHODOLOGY

We conducted a retrospective and prospective (since June 2014) study of pediatric patients with severe airway obstruction treated with biodegradable stents in our institution between 2012 and 2015. The following data were collected: demographics, indication for stenting, bronchoscopic findings, insertion technique complications, clinical outcome, stent related complications, re-stenting, and time of follow-up.

RESULTS

Thirteen custom-made polydioxanone stents were placed in four infants (mean age, 4 months) with severe tracheobronchial obstruction: tracheomalacia (two patients), bronchomalacia (1), and diffuse tracheal stenosis (1). All the stents were bronchoscopically inserted uneventfully. Immediate and maintained clinical improvement was observed in every case. No major stent related complications have occurred and only mild or moderate granulation tissue was observed during surveillance bronchoscopy. Two patients required repeated stenting as expected. All the patients are alive and in a good respiratory condition with a follow-up ranging from 5 to 40 months.

CONCLUSIONS

Biodegradable airway stents seem to be safe, effective, and cause fewer complications than other types of stents. They can be an alternative to the classic metallic or plastic stents for severe tracheal stenosis or malacia in small children. More experience is needed in order to establish the definite clinical criteria for their use in pediatric patients. Pediatr Pulmonol. 2016;51:607-612. © 2015 Wiley Periodicals, Inc.

Biodegradable polydioxanone stents in the treatment of adult patients with tracheal narrowing

Background

Biodegradable stents that disintegrate after a period of time are expected to be well tolerated and have advantages over other stents that are more commonly used in practice today. Polydioxanone is a biodegradable polymer that is widely used during surgery with absorbable sutures.

Methods

We present cases from the first four patients to undergo a tracheal polydioxanone stent insertion. Indications included significant non-malignant tracheal stenosis in cases where primary surgical treatment was not possible. The stents were implanted using rigid bronchoscopy and patients received regular follow-ups as needed. This use of biodegradable stents in adult patients was a novel, previously untested approach. The study was approved by the Institutional Ethics Committee and was based on a project entitled; “Biodegradable stents in the management of stenoses of large airways” (project NT 14146-3/2013).

Results

Six biodegradable stents were implanted in four patients with benign stenoses. No technical difficulties occurred and no serious or life-threatening events were recorded. All patients reported some benefit from treatment.

Conclusion

Polydioxanone tracheal stents can be considered when a need for temporary support is expected, and as an alternative to other stents if the latter could compromise the patient. Owing to limited experience and observed disadvantages, further research is needed to fully assess this treatment.

Trial registration

This work is based on project NT14146 - Biodegradable stents in the management of stenoses of the large airways (2013–2015, MZ0/NT), registered from May 1, 2013 in The Research and Development and Innovation Information System of the Czech Republic and in ClinicalTrials.gov, reg. no. NCT02620319, December 2, 2015.

Biodegradable Airway Stents - Bench to Bedside: A Comprehensive Review

Airway stents are indicated to treat symptomatic narrowing or to close fistulas of the central airways. They are generally divided into two types: the silicone stents and the metallic stents. Unlike in malignancies, removability is a major objective of temporary stenting in benign conditions, which poses the challenge of a new rigid bronchoscopic procedure under general anesthesia and stent removal with all its attendant risks and costs. The concept of a biodegradable (BD) stent that could maintain the patency of an airway for a predetermined duration of time is very appealing. These BD stents would gradually degrade and eventually vanish from the airway once they are no longer needed. Such stents are currently an area of intense research. Another very promising concept of drug delivery with such stents is also a very exciting area of current research. The aim of this comprehensive review is to discuss all pertinent available literature on the use of BD materials in various clinical applications and to extensively review all animal and humans trials involving BD airway stents.

Stent implantation into the tracheo-bronchial system in rabbits: histopathologic sequelae in bare metal vs. drug-eluting stents

Background

Stent implantation into the tracheo-bronchial system may be life-saving in selected pediatric patients with otherwise intractable stenosis of the upper airways. Following implantation, significant tissue proliferation may occur, requiring re-interventions. We sought to evaluate the effect of immunosuppressive coating of the stents on the extent of tissue proliferation in an animal model.

Methods

Bare metal and sirolimus-coated stents (Bx Sonic and Cypher Select, Johnson & Johnson, Cordis) were implanted into non-stenotic lower airways of New Zealand white rabbits (weight 3.1 to 4.8 kg). Three stents with sirolimus coating and six bare metal stents could be analyzed by means of histology and immunohistochemistry 12 months after implantation.

Results

On a macroscopic evaluation, all stents were partially covered with a considerable amount of whitish tissue. Histologically, these proliferations contained fiber-rich connective tissue and some fibromuscular cells without significant differences between both stent types. The superficial tissue layer was formed by typical respiratory epithelium and polygonal cells. Abundant lymphocyte infiltrations and moderate granulocyte infiltrations were found in both groups correspondingly, whereas foreign-body reaction was more pronounced around sirolimus-eluting stents.

Conclusions

After stent implantation in the tracheo-bronchial system of rabbits, we found tissue reactions comparable to those seen after stent implantation into the vascular system. There was no difference between coated and uncoated stents with regard to quality and quantity of tissue proliferation. We found, however, a significantly different inflammatory reaction with a more pronounced foreign-body reaction in sirolimus-coated stents. In our small series, drug-eluting stents did not exhibit any benefit over bare metal stents in an experimental setting.

Bronchial compression following pulmonary artery stenting in single ventricle lesions: how to prevent, and how to decompress

OBJECTIVES

To assess airway compression during pulmonary artery (PA) intervention in single ventricle (SV) palliation.

BACKGROUND

SV lesions with a prominent neo-aortic root are considered a high risk for branch PA and/or bronchial stenosis. PA stenting is well established, but may result in ipsilateral bronchial compression.

METHODS

Single-centre retrospective analysis of 19 palliated SV patients with branch PA stenosis and close proximity to the ipsilateral main bronchus who underwent cardiac catheterisation at a median age and weight of 8.5 years (0.5-25) and 16.5 kg (6-82) between 12/2011 and 05/2015.

RESULTS

Two of the 19 patients suffered an almost-closed left-main bronchus (LMB) following PA stenting. Fortunately, LMB decompression succeeded in both those patients by re-shaping the PA stents by compressing the chest while splinting the LMB with an inflated balloon. To prevent the other 17 patients from suffering this serious complication, we adopted a thorough preparation strategy: 13 patients underwent safe simultaneous bronchoscopy and cardiac catheterisation; in the remaining 4 patients CT-angiography enabled accurate risk evaluation prior to re-catheterisation.

CONCLUSIONS

In SV lesions accompanied by branch PA stenosis, thorough preparation via cross-sectional imaging is mandatory, including simultaneous bronchoscopy and cardiac catheterisation in selected cases, to rule out any airway compression before considering endovascular stent implantation. If a PA stent's compression has already caused severe bronchial obstruction, our balloon-splinted decompression technique should be considered.

Paediatrics: messages from Munich

The aim of this article is to describe paediatric highlights from the 2014 European Respiratory Society (ERS) International Congress in Munich, Germany. Abstracts from the seven groups of the ERS Paediatric Assembly (Respiratory Physiology and Sleep, Asthma and Allergy, Cystic Fibrosis, Respiratory Infection and Immunology, Neonatology and Paediatric Intensive Care, Respiratory Epidemiology, and Bronchology) are presented in the context of the current literature.

ALCAPA and massive pulmonary atelectasis: how a stent in the airway can be life-saving

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a rare congenital anomaly in which left coronary artery arises from the pulmonary artery resulting in progressive myocardial ischemia and dysfunction of the left ventricle. We report a case of ALCAPA with severe cardiac and respiratory failure and huge heart dilation compressing the left main bronchus and preventing from an effective ventilation. Emergency bronchial stenting allowed to improve left lung atelectasis, reduce pulmonary hypertension, resume anterograde left coronary artery perfusion and stabilize cardiovascular conditions to undertake a successful surgical correction.