Stent-in-stent technique for removal of the tracheal stent in patients with severe granulation tissue hyperplasia

Abstract

A tracheal stent implantation is an effective treatment for benign or malignant tracheal stenosis and tracheal fistula (1-6). Currently, covered self-expanding metal stents (SEMS) are generally used in benign cases and uncovered SEMS for treating malignant tracheal stenosis. However, the radial force of the stent on the trachea and the friction between the stent and the tracheal wall during coughing often provoke granulation tissue hyperplasia (7,8). This hyperplasia, which appears at the ends of covered stents or over the entire stented area in the case of uncovered stents, results in incarceration of the stent and tracheal restenosis (9,10). Removal of the stent is then necessary (11,12). Tracheal stent removal can result in complications such as a tracheal mucosal tear, tracheal perforation, mediastinal abscess, massive hemorrhage, and asphyxia (13-15). When the SEMS is embedded in hyperplastic granulation tissue, tracheal perforation and hemorrhage risks are especially high (16-18). Despite advances in interventional techniques and bronchoscopy, both stent removal and treatment of related complications remain difficult. Inspired by the success of the stent-in-stent (SIS) technique for esophageal stent removal (19,20), we applied it to the removal of tracheal SEMS in four patients with severe proliferative stenosis. We describe our technique and report the outcomes.