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(Chest. 2001;119:1910-1912.)
© 2001 American College of Chest Physicians

Successful Bronchoscopic Placement of Tracheobronchial Stents Without Fluoroscopy*

Felix Herth, MD; Heinrich D. Becker, MD; Joseph LoCicero, III, MD, FCCP; Robert Thurer, MD, FCCP and Armin Ernst, MD, FCCP

* From the Thoraxklinik (Drs. Herth and Becker), Heidelberg, Germany; the Department of Surgery (Drs. LoCicero and Thurer), Section of Thoracic Surgery, and the Department of Medicine (Dr. Ernst), Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Longwood Ave, Boston, MA 02215; e-mail: aernst{at}caregroup.harvard.edu


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Tracheobronchial stenting is performed increasingly often. Fluoroscopic control, which leads to significant radiation exposure for patients and staff, is recommended for the placement of metal stents.

Methods: All consecutive patients referred to two airway centers in need of airway stenting who received stents (Ultraflex; Boston Scientific, Natick, MA) underwent placement using endoscopic guidance only. All data were collected in an ongoing continuous database.

Results: One hundred stents were placed in 96 patients for central airway obstruction, and the data were reviewed. Stents were placed in all locations within the central airways for a variety of indications but mainly for malignant obstruction. No complications occurred, and all stents were placed satisfactorily.

Conclusion: At centers with dedicated airway teams, Ultraflex stents can be quickly and safely inserted without the need for fluoroscopy. This saves radiation exposure to patients and to staff and may lead to a more cost-effective procedure.

Key Words: airway stenosis • fluoroscopy • tracheobronchial stenting


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Stenting of the central airways has become a common procedure in centers treating pulmonary diseases. Various stent models are applied for endoscopic treatment, of which the silicone stent designed by Dumon1 is currently the most widely used. This prosthesis is not exempt from complications, the most important of which are migration and inflammatory granulation.2 Based on experience acquired in angiology, new self-expandable metallic prostheses have made their appearance on the market within the past several years with good success.3 4 At the moment, the positioning of these stents is performed mostly under fluoroscopic control.5 This requires fluoroscopy equipment and additional staff, and it causes radiation exposure for patients and the staff. Therefore, in our study we investigated the feasibility of tracheobronchial stent placement under direct visual control without using fluoroscopy.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
A prospective data collection was performed from January 1998 to July 1999 in all patients requiring tracheobronchial stenting. This report includes all consecutive patient who during this period of time received a stent (Ultraflex; Boston Scientific; Natick, MA). Thoraxklinik Heidelberg and Beth Israel Deaconess Medical Center are referral centers for patients with airway problems, and both facilities operate dedicated multidisciplinary airway teams. Airway stenting in patients is performed only if the team agrees that this is the most appropriate option available. Silicone and metal stents are both in use. Tracheobronchial stenting is commonly part of a multimodality intervention, which may include laser therapy and other kinds of therapy. Stents are placed only by operators who are well-versed in all aspects of therapeutic bronchoscopy.

Description of the Device
The Ultraflex stent is a self-expanding, knitted metallic meshwork made from a nickel-titanium alloy. This alloy has shape memory properties. Most commonly, a covered version is used that is coated by a polyurethane membrane, but for mere external compression or malacia an uncovered version is also available. For fixation of the covered stent, the last few millimeters on each end are left uncovered to allow better integration into the bronchial wall. Ultraflex stents come in a variety of lengths and diameters. They are mounted on an introducer catheter that has radiopaque markers (Fig 1 ).



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  		Figure 1.. Ultraflex airway stent mounted on an introducer device. A single thread applied in a crochet technique retains the stent. Pulling at the dedicated end releases the stent.

 
Placement Technique
Metallic stent placement is possible both with the rigid and the flexible bronchoscope.5 For proper stent selection, the diameter and the length of the stenosis are measured carefully. Sometimes prior dilatation or endoluminal tumor resection of the stenotic area is necessary. The diameter is assessed in relation to the barrel of the endoscope or to the opening of the branches of a biopsy forceps and by assessing airway sizes by CT scan, if available. The length of the stenosis is determined on the endoscope by withdrawing the instrument from the distal to the proximal end of the stenosis. A guidewire then is introduced, and the stent is placed over it. With the use of the flexible bronchoscope, the guidewire is sent through the channel and the scope is then removed in a sleeve-like fashion. The bronchoscope then is reintroduced next to the guidewire. With the use of the rigid scope, the guidewire can usually be directly advanced through the barrel. The distal end of the stent is advanced beyond the narrowed area until the middle of the stent is located adjacent to the area in question. During the procedure, the release of the stent is directly observed through the bronchoscope, and gradual detachment from the catheter follows under visual control (Fig 2 ).



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  		Figure 2.. Endoscopic image of stent placement. Left: a partially deployed stent is shown. Right: the stent is shown fully in place.

 
At both ends of the stent, a thread is filed through the last loops of the meshwork. By smoothly pulling the thread with a forceps, the end of the stent tapers like the opening of a purse and can be pulled upward toward the tip of the endoscope for proximal repositioning or pushed downward for distal repositioning.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Patients and Indications
Between the two institutions, 96 consecutive patients who had undergone 100 Ultraflex stent placements were reviewed. There were 60 men and 36 women with a mean age of 59.8 years (age range, 26 to 92 years). The indication for stenting in 90 cases was high-grade airway stenosis, and in 10 cases it was an tracheoesophageal fistula. Fifty-two procedures were performed by flexible bronchoscopy, and 48 procedures were performed by rigid bronchoscopy. In 42 cases, the uncovered type of stent was introduced, and in 58, the covered type was introduced. All procedures with the flexible bronchoscope were performed under conscious sedation only.

The etiologies of the airway obstructions necessitating stent placement are detailed in Table 1 , the most common indications being non-small cell lung cancer and esophageal cancer. Twenty-one stents were placed for benign indications.


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  		Table 1.. Diagnoses Leading to Stent Placement

 
Site of Placement
The localization of stent placements is shown in Table 2 . The trachea was the most commonly stented region, but even small airways were successfully treated.


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  		Table 2.. Localization of Stents

 
Placement
The extent of the endobronchial lesions and the proper positioning of all stents were confirmed by direct visualization. None of the procedures re- quired fluoroscopy to achieve proper stent placement. There were no complications. None of the patients required stent replacement or significant repositioning.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The Ultraflex stent is a self-expanding metallic device that is made of a so-called memory metal alloy of nickel and titanium. Traditionally, tracheobronchial metal stent placement is performed with fluoroscopic guidance, which requires specialized radiology equipment and, thus, is associated with higher cost and greater radiation exposure for patients and staff. This recommendation by the manufacturer is not based on studies demonstrating added safety from that approach for tracheobronchial stent placement but may rather be a carry-over from other medical specialties using stents, such as in radiology.

The results of our study establish the safety of placement of the Ultraflex stents under visual control without the need for fluoroscopy. Insertion of the device with the flexible or rigid bronchoscope under visual control proved to be relatively simple.

It is necessary to point out that even though this approach simplifies the placement of this particular stent, a variety of other stent types are available. Other types, such as silicone stents, may be better suited to some problems, and decisions about what stent to use can be made best at dedicated centers with all options available.

In conclusion, we demonstrated that endobronchial placement of the Ultraflex stents can be successfully and easily performed without the need for special radiologic facilities and radiation exposure. These findings apply to centers with dedicated airway teams and a large experience in placing these airway devices.

Received for publication April 7, 2000. Accepted for publication December 7, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Dumon, JF (1990) A dedicated tracheobronchial stent. Chest 97,328-332[Abstract/Free Full Text]
  2. Colt, HC, Dumon, JF (1991) Airway obstruction in cancer: the pros and cons of stents. J Respir Dis 12,741-749
  3. Miyazawa, T (1999) Therapeutic bronchoscopy: laser-stents. J Jpn Soc Bronchol 21,545-552
  4. Becker, HD (1996) Options and results in endobronchial treatment of lung cancer. Minim Invasive Ther Allied Technol 5,165-178
  5. Dasgupta, A, Dolmbatch, BL, Abi-Saleh, WJ, et al (1998) Self-expandable metallic airway stent insertion employing flexible bronchoscopy. Chest 114,106-109[Abstract/Free Full Text]



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