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Department of Internal Medicine Department of Pulmonary and Critical Care Medicine The Cleveland Clinic Foundation Cleveland, OH
To the Editor:
We would like to report an incidence of breakage and expulsion of a wire mesh stent (Wallstent; Schneider; Minneapolis, MN) in a patient who required multiple stents for idiopathic tracheobronchomalacia.
A 69-year-old man with tracheobronchomalacia had two Wallstents inserted in the trachea and left main bronchus (LMB) in February 1996. He did well for approximately 11/2 years and returned with increasing shortness of breath. Flexible bronchoscopy in October 1997 revealed granulomas involving the stents, and the lower end of the tracheal stent was overhanging the LMB. Both of the granulomas and the lower portion of the tracheal stent were ablated with Nd-YAG laser photoresection. A Rusch Y stent was inserted in the trachea after balloon dilation of the existing tracheal stent. The Rusch Y stent had to be subsequently removed in December 1997 because of frequent mucous plugging.
The patient returned 3 months later with an "exacerbation of asthma," of 1 week's duration and had coughed up two wire stent fragments (Fig 1) . Bronchoscopy at the time revealed wires protruding from an intact tracheal stent (Fig 2) and dynamic collapse of the posterior wall of the trachea. No intervention was done at that time. The patient returned again in June 1998 after having coughed up two more pieces of wire stent fragments while having swallowed the third one.
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Flexible bronchoscopy is being increasingly used to insert self-expandable metallic stents for management of large airway obstruction.1 2 3 Though complications of Wallstents like stent migration, granuloma formation, infection, and stent expulsion have been reported, to our knowledge, this is the first incident of spontaneous breakage and expulsion of wire stent fragments. We speculate that damage to the stent occurred during subsequent manipulation through the stent, and spontaneous breakage occurred by the dynamic maneuvers, like coughing.
We highlight this occurrence as a reminder that Wallstents are delicate, and one needs to be careful about forcible manipulation through the stent. It also raises concern about structural manipulation of the Wallstent, for example, by laser ablation. If such manipulations are mandatory, then patients should be warned of later expulsion of wires to decrease their anxiety. This is also likely to lead to loss of stent function, which may require insertion of a second stent through the first stent.
Correspondence to: Atul C. Mehta, MBBS, FCCP, Department of Pulmonary/Critical Care Medicine, A-90, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
References
This article has been cited by other articles:
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  M. Noppen, G. Stratakos, J. D'Haese, M. Meysman, and W. Vinken Removal of Covered Self-Expandable Metallic Airway Stents in Benign Disorders: Indications, Technique, and Outcomes Chest, February 1, 2005; 127(2): 482 - 487. [Abstract] [Full Text] [PDF]
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