Unilateral arytenoid lateralisation and extraluminal polypropylene ring prostheses for correction of tracheal collapse in the dog

A systematic review and meta-analysis of prevalence of complications after tracheal stenting in dogs

BACKGROUND

Stenting has become popular to treat tracheal collapse in dogs, but complications might arise and negatively affect treatment outcome.

OBJECTIVES

Determine the overall prevalence of complications of tracheal stenting in dogs.

METHODS

A bibliographic search was performed of publications from 2000 to 2020. Studies were assessed for quality of evidence and measured prevalence of the 8 most commonly reported complications after tracheal stenting in dogs (stent fracture, stent migration, relapsing collapse, granuloma formation, tracheobronchial infections, and early, late, and clinically relevant late cough). Random effects meta-analyses were used to estimate pooled complications prevalence.

RESULTS

Fifteen studies met inclusion criteria. Cough (early: 99%; 95% confidence interval [95% CI]: 95%-100%, late: 75%; 95% CI: 63%-85%, and clinically relevant: 52%; 95% CI: 42%-61%), tracheobronchial infections (24%; 95% CI: 14%-35%), and granulomas (20%; 95% CI: 11%-30%) were common after tracheal stenting. Stent fractures (12%; 95% CI: 5%-20%), relapsing collapse (10%; 95% CI: 5%-15%), and stent migration (5%; 95% CI: 1%-9%) were less frequent. Significant heterogeneity among studies was identified for the estimated prevalence of stent fracture, granulomas, infections, and late cough.

CONCLUSIONS AND CLINICAL IMPORTANCE

Tracheal stenting in dogs is associated with a high risk of coughing and a moderate risk of tracheobronchial infections and granuloma formation. Because most complications will impact a dog's quality of life, owners must be informed that tracheal stenting is a second-line procedure that does not necessarily alleviate the need for medical treatment and frequent follow-up visits. Additional studies are warranted to identify the risk factors of these complications.

Stents in Veterinary Medicine

Stenting in veterinary medicine has been a rapidly growing method of interventional surgery for several years. This procedure is usually performed in the respiratory and urinary tracts, but there are cases of stenting of blood vessels or gastrointestinal structures. It is based on maintaining the permeability of a given tubular structure, thus allowing the passage of gas or liquid. This procedure is often performed as a first-line treatment in situations where pharmacological agents do not work and as an alternative method, often cheaper than the classically performed ones. There are also cases where stenting is used as a palliative treatment, e.g., to enable defecation in colonic obstruction due to tumour infiltration of the colon wall. Stenting is often a life-saving or comfort-improving procedure for animals, but one should also be aware of possible postoperative complications and be prepared for any adversity. For this reason, this review provides an insight into the current knowledge in veterinary medicine about stenting and the consequences associated with this procedure.

Self-expanding tracheal stent placement in a cat with primary tracheal collapse

A 12-year-old mixed-breed spayed female cat presented with dyspnoea, open-mouthed breathing, and cyanosis that was difficult to control with medical pharmacotherapy; the cat was diagnosed with the primary tracheal collapse of the neck and chest regions. The diagnosis was confirmed by dynamic chest radiography, tracheal endoscopy, and computed tomography (CT). Tracheal endoscopy and CT showed dropsy of the dorsal membranous wall over most of the trachea. A self-expanding Nitinol cross-and-hook braided stent was placed along the entire tracheal lumen using surgical X-ray fluoroscopy. Bacterial cultures in the trachea were negative. Dyspnoea disappeared immediately after the endotracheal stent was implanted. Although the long-term prognosis remains under observation, the short- to medium-term prognosis was very good. These results suggest that stenting may be useful in the treatment of primary tracheal collapse in cats.

Surgical outcomes in dogs with tracheal collapse treated with a novel cross-and-hook braided endoluminal stent

Background

Stenting is an effective treatment option for tracheal collapse in dogs. Cross-braided tracheal stents are currently the norm in veterinary medicine, but cross-and-hook braided stents have recently been adopted in human medicine. We examined whether stents manufactured using this novel braiding technique provided additional advantages for the treatment of tracheal collapse in dogs.

Objectives

To evaluate the outcomes of cross-and-hook braided stent implantation in the treatment of tracheal collapse in dogs.

Methods

The medical records of 22 client-owned dogs that underwent luminal placement of cross-and-hook braided Fauna Stents for the treatment of tracheal collapse between January 2018 and July 2021 were examined and data on canine signalment, clinical signs, diagnostic test results, surgical outcomes, and postoperative complications were retrieved and analyzed statistically.

Results

Twenty-six stents were surgically implanted, with 20 dogs (90.9%) receiving one stent and the remaining two (9.1%) receiving two or more stents. All dogs survived the procedure. The median survival time at a median follow-up of 990 days was 879 days. At the final follow-up examination, loss or mild improvement of cough was observed in all dogs.

Conclusions

Compared with conventional lumen stents, the cross-and-hook braided Fauna Stent offered a higher survival rate and improved clinical symptoms in all patients. The results of this study suggest that the Fauna Stent may be a promising treatment option for dogs with tracheal collapse.

An Update on Tracheal and Airway Collapse in Dogs

Tracheal and airway collapse (bronchomalacia) are common causes of chronic cough in middle-aged to older dogs in which weakening of cartilage within the respiratory system leads to narrowing of airways, irritation, inflammation, partial to complete airway obstruction, and other secondary effects. Tracheomalacia occurs in small-breed dogs, whereas bronchomalacia can occur in any size dog. Successful treatment involves correct identification of the problem, recognition of concurrent disease processes, and appropriate medical therapy. Surgical intervention and intraluminal stenting are readily available so it is important to understand indications for such procedures.

Ex vivo investigation of the effect of the transverse arytenoid ligament on abduction of the arytenoid cartilage when performing equine laryngoplasty

Aims: To investigate the effect of the transverse arytenoid ligament (TAL) on abduction of the arytenoid cartilage when performing laryngoplasty. Methods: Modified prosthetic laryngoplasty was performed on right and left sides of 13 cadaver larynges. Increasing force was sequentially applied to the left arytenoid cartilage at 3 N intervals from 0-24 N, when the force on the right arytenoid cartilage was either 0 or 24 N, before and after TAL transection. Digital photographs of the rostral aspect of the larynx were used to determine the left arytenoid abduction angles for these given force combinations and results compared before and after TAL transection. Longitudinal and transverse sections of the TAL from seven other equine larynges were also examined histologically. Results: Increasing force on the left arytenoid cartilage from 0-24 N produced a progressive increase in the angle of the left arytenoid cartilage (p < 0.001) and increasing force on the right arytenoid cartilage from 0-24 N reduced the angle of the left arytenoid cartilage (p < 0.001). Following transection of the TAL the mean angle of the left arytenoid increased from 36.7 (95% CI = 30.5-42.8)° to 38.4 (95% CI = 32.3-44.5)°. Histological examination showed that the TAL was not a discrete ligament between the arytenoid cartilages but was formed by the convergence of the ligament and the left and right arytenoideus transversus muscles. Conclusions: Transection of the TAL in ex vivo equine larynges enabled greater abduction of the left arytenoid cartilage for a given force. These results indicate that TAL transection in conjunction with prosthetic laryngoplasty may have value, but the efficacy and safety of TAL transection under load in vivo, and in horses clinically affected with recurrent laryngeal neuropathy must be evaluated. Abbreviations: F_max: Force needed to maximally abduct the left or right arytenoid; TAL: Transverse arytenoid ligament.

Immediate, short-, and long-term changes in tracheal stent diameter, length, and positioning after placement in dogs with tracheal collapse syndrome

BACKGROUND

Intraluminal tracheal stenting is a minimally invasive procedure shown to have variable degrees of success in managing clinical signs associated with tracheal collapse syndrome (CTCS) in dogs.

OBJECTIVES

Identify immediate post-stent changes in tracheal diameter, determine the extent of stent migration, and stent shortening after stent placement in the immediate-, short-, and long-term periods, and evaluate inter-observer reliability of radiographic measurements.

ANIMALS

Fifty client-owned dogs.

METHODS

Retrospective study in which medical records were reviewed in dogs with CTCS treated with an intraluminal tracheal stent. Data collected included signalment, location, and type of collapse, stent diameter and length, and post-stent placement radiographic follow-up times. Radiographs were used to obtain pre-stent tracheal measurements and post-stent placement measurements.

RESULTS

Immediate mean percentage change was 5.14%, 5.49%, and 21.64% for cervical, thoracic inlet, and intra-thoracic tracheal diameters, respectively. Ultimate mean follow-up time was 446 days, with mean percentage change of 2.55%, 15.09%, and 8.65% for cervical, thoracic inlet, and intra-thoracic tracheal diameters, respectively. Initial mean stent length was 26.72% higher than nominal length and ultimate long-term tracheal mean stent shortening was only 9.90%. No significant stent migration was identified in the immediate, short-, or long-term periods. Good inter-observer agreement of radiographic measurements was found among observers of variable experience level.

CONCLUSIONS AND CLINICAL IMPORTANCE

Use of an intraluminal tracheal stent for CTCS is associated with minimal stent shortening with no clinically relevant stent migration after fluoroscopic placement. Precise stent sizing and placement techniques likely play important roles in avoiding these reported complications.

Long-term outcome, complications and disease progression in 23 dogs after placement of tracheal ring prostheses for treatment of extrathoracic tracheal collapse

OBJECTIVE

To report complications, long-term outcome, and disease progression in dogs with extrathoracic tracheal collapse treated by surgical placement of commercially available extraluminal rings.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n = 23).

METHODS

Medical records (2002-2011) of dogs treated with extraluminal rings for extrathoracic tracheal collapse were reviewed. Owner interviews, conducted at >10 months postoperatively, determined response to surgery, progression of clinical signs after surgery, and frequency of medication administration. Long-term re-evaluation (>10 months after surgery) was offered for surviving dogs, including radiographs and tracheoscopy if indicated.

RESULTS

Of 23 dogs, 22 survived to discharge after surgery. Clinical signs improved in all dogs at 2 weeks after surgery and at long-term re-evaluation. Fourteen dogs (65%) required no medical management for respiratory signs after surgery. Four dogs (17%) were diagnosed with laryngeal paralysis at some point after surgery, but only 9% were diagnosed within 48 hours of the surgery. Additional rings were placed between previously placed rings in 2 dogs, and 1 dog was treated with an endoluminal stent for intrathoracic tracheal collapse. Three dogs had clinical signs consistent with progression of tracheal collapse. Based on owner questionnaire, all owners were satisfied with surgical outcome.

CONCLUSIONS

Treatment of severe cervical tracheal collapse with commercially-available extraluminal ring placement leads to an overall improvement in quality of life and good long-term results, with about one-third of dogs requiring continued medical management. Most dogs do not have clinical signs consistent with disease progression after surgery.

Tracheal and airway collapse in dogs

Tracheal and airway collapse (bronchomalacia) are common causes of chronic cough in middle-aged to older dogs where weakening of cartilage within the respiratory system leads to narrowing of airways, coughing, wheezing, and other secondary effects. Successful treatment involves correct identification of the problem, recognition of concurrent problems, and appropriate medical therapy. Surgical and noninvasive treatment options are becoming readily available, and it is important to understand indications for such procedures.

Survival after surgery for tracheal collapse and the effect of intrathoracic collapse on survival

OBJECTIVES

To determine (1) long-term survival of dogs with tracheal collapse (TC) receiving cervical extraluminal prosthetic rings (ELR) and (2) whether intrathoracic collapse effects long-term survival of dogs receiving ELR.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n = 33) with TC that had ELR.

METHODS

Medical records (July 2002-July 2008) were searched for TC dogs treated with ELR. Age, breed, gender, location of TC, and age at follow-up (death or censor) were recorded. Kaplan-Meier survival curves were generated.

RESULTS

Of 114 TC dogs, 33 had ELR. Breeds and gender were consistent with previous reports; mean (±SD) age at presentation was 6.3±2.6 years. TC was categorized as cervical or cervical and intrathoracic. All dogs had cervical TC and 15 had concurrent intrathoracic collapse; 8 of these had collapse of mainstem bronchi. Median survival time was >2500 days (median not reached) for cervical TC alone and 1500 days for cervical and intrathoracic TC with no difference in median survival time between groups (P = .26).

CONCLUSION

Dogs with TC have a median survival time of 1680 days (4.6 years) after ELR and no differences were seen when dogs had intrathoracic collapse. Intrathoracic collapse does not exclude a dog from receiving ELR.

Arytenoid lateralization for management of combined laryngeal paralysis and laryngeal collapse in small dogs

OBJECTIVE

To identify combined laryngeal paralysis and collapse in small dogs and describe postoperative outcome after arytenoid lateralization.

STUDY DESIGN

Case series.

ANIMALS

Small nonbrachycephalic breed dogs with laryngeal paralysis and collapse (n = 6).

METHODS

Medical records of small breed dogs with airway problems and undergoing laryngeal surgery (January-December 2008) were reviewed. Dogs with combined laryngeal paralysis and laryngeal collapse (LPLC) had arytenoid lateralization. The immediate, 4 week and 6 month postoperative outcomes were described.

RESULTS

Direct visual laryngeal exam under a light plane of anesthesia revealed bilateral failure of arytenoid and vocal fold movement and concurrent bilateral medial folding with contact of the cuneiform processes in all dogs. None of the dogs had intra- or immediate postoperative complications after arytenoid lateralization. Two dogs required a 2nd contralateral procedure. Follow-up after 6 months revealed marked improvement in clinical signs related to upper airway obstruction, but all dogs continued to have mild respiratory noise.

CONCLUSION

Concurrent laryngeal paralysis and collapse should be considered as part of the differential diagnosis for small, nonbrachycephalic dogs with upper airway disease. Arytenoid lateralization resulted in improvement of clinical signs related to obstructive airway disease.

Primary Tracheal Collapse in a Cat

A 7-year-old, neutered male, domestic shorthair cat was presented for severe inspiratory dyspnea of 2 to 3 days’ duration. Radiography and tracheobronchoscopy confirmed the diagnosis of primary extrathoracic tracheal collapse. The cat was treated with oxygen, dexamethasone, and terbutaline, but no improvement was seen. Surgical correction was performed using nine prosthetic tracheal ring implants. Clinical signs improved after surgery, and the cat continued to do well 11 months after surgery, despite development of unilateral laryngeal paralysis.

Endotracheal stenting therapy in dogs with tracheal collapse

Tracheal collapse in dogs is a common respiratory disorder, typically presenting with a history of chronic cough, increasing respiratory difficulties, and episodes of dyspnoea. Medical treatment is the therapy of choice and surgical repair is considered when patients do not respond well. Minimally invasive endotracheal stenting is a promising new therapy under investigation, but there remain significant challenges to overcome potential complications. The purpose of this article is to provide a comparative overview of intra-luminal stenting of the trachea in human and veterinary medicine. The currently available stents and their potential clinical application to the veterinary patient will be discussed.

Fluoroscopic and radiographic evaluation of tracheal collapse in dogs: 62 cases (2001–2006)

OBJECTIVE

To compare the use of radiography and fluoroscopy for detection and grading of tracheal collapse in dogs.

DESIGN

Retrospective case series. Animals-62 dogs with tracheal collapse.

PROCEDURES

For each dog, tracheal collapse was confirmed fluoroscopically and lateral cervical and thoracic radiographic views were reviewed. A board-certified radiologist (who was unaware of the dogs' clinical history) evaluated the cervical, thoracic inlet, thoracic, carinal, and main stem bronchial regions in all fluoroscopic videos and radiographic images for evidence of collapse. Cervical, thoracic inlet, thoracic, and carinal regions in both radio-graphic and fluoroscopic studies were graded for collapse (0%, 25%, 50%, 75%, or 100% decrease in diameter).

RESULTS

Lateral cervical and thoracic radiographic images were available for 54 dogs, and inspiratory and expiratory lateral cervical and thoracic radiographic images were available for 8 dogs. For detection of tracheal collapse, assessment of radiographic views was sensitive and had the best negative predictive value in the cervical and thoracic inlet regions. Assessment of radiographic views was most specific and had the best positive predictive value in the thoracic inlet, thoracic, carina, and main stem bronchial regions. Radiography underestimated the degree of collapse in all areas. Review of inspiratory and expiratory views improved the accuracy of radiography for tracheal collapse diagnosis only slightly.

CONCLUSIONS AND CLINICAL RELEVANCE

Compared with fluoroscopy, radiography underestimated the frequency and degree of tracheal collapse. However, radiography appears to be useful for screening dogs with potential tracheal collapse.

Tracheal collapse. Diagnosis and medical and surgical treatment

Tracheal collapse remains a common clinical problem in middle-aged, small-breed dogs. Clinical signs are characteristic, and the diagnostic work-up serves to identify predisposing triggers of disease and to allow optimization of therapy for individual animals. Bronchoscopic confirmation of airway collapse aids in characterizing the extent of airway damage and allows collection of airway samples to rule out infectious or inflammatory airway disease. Once coincident diseases have been managed, cough suppressants are used to control signs and reduce chronic airway injury.

Surgically treatable upper respiratory disorders

Diseases of the upper airways and trachea frequently result in inspiratory dyspnea, and surgery is often required to alleviate symptoms arising from these disorders. Although surgery alone may not effectively treat all diseases of the nasal cavity and sinuses, surgery allows removal of foreign bodies that cannot be retrieved endoscopically and may facilitate treatment of other disorders. Indications for surgery are discussed, and principles of surgery of the upper airways are reviewed.