Silicone Y stent placement at secondary left carina for malignant central airway obstruction

Abstract

The Y silicone stents are shaped with long tracheal and left main bronchial limbs and a shorter right main bronchial limb. These stents can be used for patients with fixed or dynamic central airway obstruction from benign or malignant disease. 1 More often, these stents are used for patients with extensive tumor involvement in the lower trachea and mainstem bronchi. 2 To our knowledge, their use specifically for unilateral central airway obstruction has not been previously published. In this report, we describe the indication, method, and outcome of Y stent insertion at the level of the secondary left carina separating the left upper and lower lobe bronchi, to restore airway patency ofthe left lobar bronchi in a patient with primary squamous cell lung cancer. CLINICAL SUMMARY A7 3-year-old man with hemoptysis was found to have a left infrahilar mass involving the distal left main bronchus and the entrance of the lobar bronchi (Figure 1). Rigid bronchoscopy, neodymium:yttrium-aluminum-garnet laser photocoagulation and debulking was performed under general anesthesia with assisted spontaneous ventilation using a 13-mm Efer-Dumon rigid ventilating bronchoscope (Bryan Corporation, Woburn, Mass). Tumor infiltration, cartilaginous collapse, and extrinsic compression prompted insertion of a Y silicone stent (16-mmdiameter tracheal, 12-mm-diameter bronchial limbs) within the left main bronchus. The left bronchial limb was shortened to 1.5 cm using a scalpel prior to loading the longitudinally folded stent into a large, rigid, stent introducer tube. The stent was then deployed into the entrance of the left upper lobe bronchus. While the stent was still partially folded along its long axis, rigid forceps were used to grasp the stent and pull it proximally into the distal left main bronchus, allowing unfolding of the right bronchial limb into the relatively straight left lower lobe bronchus. Forceps were then used to push the stent down onto the secondary left carinal spur. The right limb of the Y stent was thus directed into the left lower lobe bronchus while the left limb was shortened to provide access into the left upper lobe bronchus (Figure 2). There were no perioperative complications. The patient received chemotherapy and radiation therapy. Bronchoscopy 4 months later revealed patent airways and no evidence of stent-related complications. At 1-year follow-up, the patient’s airways remain patent.